Reorienting programme budgeting and marginal analysis (PBMA) towards disinvestment

<p>Abstract</p> <p>Background</p> <p>Remarkable progress has been made over the past 40 years in developing rational, evidence-based mechanisms for the allocation of health resources. Much of this progress has centred on mechanisms for commissioning new medical devices and pharmaceuticals. The attention of fund-managers and policy-makers is only now turning towards development of mechanisms for decommissioning, disinvesting or redeploying resources from currently funded interventions. While Programme Budgeting and Marginal Analysis would seem well-suited to this purpose, past applications include both successes and failures in achieving disinvestment and resource release.</p> <p>Discussion</p> <p>Drawing on recent successes/failures in achieving disinvestment and resource release via PBMA, this paper identifies four barriers/enablers to disinvestment via PBMA: (i) specification of the budget constraint, (ii) scope of the programme budget, (iii) composition and role of the advisory group, and (iv) incentives for/against contributing to a 'shift list' of options for disinvestment and resource release. A number of modifications to the PBMA process are then proposed with the aim of reorienting PBMA towards disinvestment.</p> <p>Summary</p> <p>The reoriented model is differentiated by four features: (i) hard budget constraint with budgetary pressure; (ii) programme budgets with broad scope but specific investment proposals linked to disinvestment proposals with similar input requirements; (iii) advisory/working groups that include equal representation of sectional interests plus additional members with responsibility for advocating in favour of disinvestment, (iv) 'shift lists' populated and developed prior to 'wish lists' and investment proposals linked to disinvestment proposals within a relatively narrow budget area. While the argument and evidence presented here suggest that the reoriented model will facilitate disinvestment and resource release, this remains an empirical question. Likewise, further research will be required to determine whether or not the re-oriented model sacrifices feasibility and acceptability to obtain its hypothesised greater emphasis on disinvestment.</p

Is the value of a life or life-year saved context specific? Further evidence from a discrete choice experiment

<p>Abstract</p> <p>Background</p> <p>A number of recent findings imply that the value of a life saved, life-year (LY) saved or quality-adjusted life year (QALY) saved varies depending on the characteristics of the life, LY or QALY under consideration. Despite these findings, budget allocations continue to be made as if all healthy life-years are equivalent. This continued focus on simple health maximisation is partly attributable to gaps in the available evidence. The present study attempts to close some of these gaps.</p> <p>Methods</p> <p>Discrete choice experiment to estimate the marginal rate of substitution between cost, effectiveness and various non-health arguments. Odds of selecting profile B over profile A estimated via binary logistic regression. Marginal rates of substitution between attributes (including cost) then derived from estimated regression coefficients.</p> <p>Results</p> <p>Respondents were more likely to select less costly, more effective interventions with a strong evidence base where the beneficiary did not contribute to their illness. Results also suggest that respondents preferred prevention over cure. Interventions for young children were most preferred, followed by interventions for young adults, then interventions for working age adults and with interventions targeted at the elderly given lowest priority.</p> <p>Conclusion</p> <p>Results confirm that a trade-off exists between cost, effectiveness and non-health arguments when respondents prioritise health programs. That said, it is true that respondents were more likely to select less costly, more effective interventions – confirming that it is an adjustment to, rather than an outright rejection of, simple health maximisation that is required.</p

A population-based model for priority setting across the care continuum and across modalities

BACKGROUND: The Health-sector Wide (HsW) priority setting model is designed to shift the focus of priority setting away from 'program budgets' – that are typically defined by modality or disease-stage – and towards well-defined target populations with a particular disease/health problem. METHODS: The key features of the HsW model are i) a disease/health problem framework, ii) a sequential approach to covering the entire health sector, iii) comprehensiveness of scope in identifying intervention options and iv) the use of objective evidence. The HsW model redefines the unit of analysis over which priorities are set to include all mutually exclusive and complementary interventions for the prevention and treatment of each disease/health problem under consideration. The HsW model is therefore incompatible with the fragmented approach to priority setting across multiple program budgets that currently characterises allocation in many health systems. The HsW model employs standard cost-utility analyses and decision-rules with the aim of maximising QALYs contingent upon the global budget constraint for the set of diseases/health problems under consideration. It is recognised that the objective function may include non-health arguments that would imply a departure from simple QALY maximisation and that political constraints frequently limit degrees of freedom. In addressing these broader considerations, the HsW model can be modified to maximise value-weighted QALYs contingent upon the global budget constraint and any political constraints bearing upon allocation decisions. RESULTS: The HsW model has been applied in several contexts, recently to osteoarthritis, that has demonstrated both its practical application and its capacity to derive clear evidenced-based policy recommendations. CONCLUSION: Comparisons with other approaches to priority setting, such as Programme Budgeting and Marginal Analysis (PBMA) and modality-based cost-effectiveness comparisons, as typified by Australia's Pharmaceutical Benefits Advisory Committee process for the listing of pharmaceuticals for government funding, demonstrate the value added by the HsW model notably in its greater likelihood of contributing to allocative efficiency

Review of Australian health economic evaluation – 245 interventions: what can we say about cost effectiveness?

© 2008 Dalziel et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution Licens

Moist Wound Dressings and Pressure Relieving Surfaces : Mechanisms, Materials and a Review of Some Cost-Effectiveness Findings

This paper is intended to provide background to guide future work in establishing the cost-effectiveness of modern wound care practices. An outline of the rationale, indications and effectiveness is given for two aspects of the total wound care protocol: pressure relief and moist wound dressings. Against this background of mechanisms and materials for wound healing, methodology employed in reported cost-effectiveness studies is appraised with a view to identifying a set of rigorous studies that might accurately reflect the value of adopting alternative wound care methods as part of a standard treatment protocol. Several methodological shortcomings were identified in the studies reviewed. Moreover, these studies generally fell well short of the rigorous application of CEA methods necessary to inform questions of resource allocation at the societal level. Nonetheless, reviewed findings provide a guide to the magnitude of key factors influencing the cost-effectiveness of pressure relieving surfaces and moist wound healing. Further, modelling cost-effectiveness around reviewed findings could well produce robust estimates of C/E suitable to guide resource allocation

Competing Methods for Efficiency Measurement : A Systematic Review of Direct DEA vs SFA/DFA Comparisons

Various authors have advised a wait and see approach in evaluating the relative precision of alternative techniques, such as data envelopment analysis (DEA) and stochastic frontier analysis (SFA), in estimating industry-average and firm-specific inefficiency. Chirikos and Sear (2000), for example, contend that "policy-makers may be well advised to wait until additional research clarifies reasons why DEA and stochastic frontier models yield divergent results" (p. 1389). The main objective of this paper is to highlight the likely trade-offs between competing methods based on direct empirical comparisons using simulated data and to demonstrate the wealth of evidence bearing on a range of real-world applications. Whilst this systematic review indicates that a good deal of evidence is already available, evidence of a different sort may be required to identify a `correct' approach in addressing specific policy problems. In particular, the now routine practice of cross checking should be taken one step further to include realistic simulation studies along-side real-world DEA vs SFA comparisons

The Art of Reason versus the Exactness of Science in Elite Refereeing: Comments on Plessner and Betsch (2001)

Plessner and Betsch’s (2001) investigation into officiating behavior may be representative of a shift from stress-orientated research (Anshel &amp; Weinberg, 1995; Rainey &amp; Winterich, 1995; Stewart &amp; Ellery, 1996) to consideration of decisionmaking (Craven, 1998; Ford, Gallagher, Lacy, Bridwell &amp; Goodwin, 1999; Oudejans, Verheijen, Bakker, Gerrits, Steinbuckner &amp; Beek, 2000), the primary function of referees in any sport. Commendably, Plessner and Betsch have investigated the most important focus of referee performance, the application of the rules (Anshel, 1995). However, methodological weaknesses, together with a fundamental error in the attribution of causation to the findings, significantly dilute this paper’s contribution to extending knowledge in this important area

Elite Refereeing Performance:Developing a Modelfor Sport Science Support

To identify a framework for referee training and selection, based on the key areas of effective performance, we conducted content analyses on Rugby Football Union referee assessor reports, referee training materials, performance profiles from a group of English premier league referees, and a review of published research on sports officiating. The Cornerstones Performance Model of Refereeing emerged, overarched by the psychological characteristics of excellence (see McCaffrey &amp; Orlick, 1989) and featuring four key areas; (a) knowledge and application of the law; (b) contextual judgment; (c) personality and management skills; and (d) fitness, positioning and mechanics. Focus group interviews confirmed the usefulness of the model as an assessment and training tool, which the RFU now use to develop referees throughout Englan