Are Publicly Financed Dental Care
Programs in Ontario Delivering the
“Best Bang for their Buck?”
E. Cardoso, V. Pilly, C. Quiñonez
1
Outline
• Current situation
• Strategies abroad
• Conceptual framework
• Multi-Criteria Decision Analysis (MCDA) tool
• Strengths & Weaknesses
• Conclusion
2
Current situation
• Imbalance between financial resources and
challenges
– Increasing demand
– Higher costs
– Ethical dilemmas
(Xie et al., 2011)
• Sustainability of dental care programs
• Recent call to increase access
3
Current situation
• Challenge = Opportunity
– Chase the “best bang for their buck”
– Enhance process effectiveness & health outcomes
• Mantra of “no new dollars”
– Scrutinize the basket of dental care services
– Resource allocation optimization
(Elshaug et al., 2009)
– Evidence and best practices
4
Strategies abroad
Identify interventions with questionable
outcomes
(Garner & Littlejohns , 2011)
Identify unsafe or ineffective services
(Elshaug et al., 2012)
Ethical principles for resource allocation
(WHO,2004)
5
Conceptual framework
• Decision support tool
– Multi-Criteria Decision Analysis (MCDA)
– Health Technology Assessment (HTA)
• Evaluate existing or future practices
• Evaluation phase or planning phase
• Help decision action toward program objectives
6
Procedure
Program Objectives Analysis
Are program
objectives
met?
No
Yes
Analysis against need
No
Is procedure
needed?
Yes
Do not
fund
Analysis against effectiveness
No
Is procedure
effective?
Yes
Analysis against
appropriateness
No
Is procedure
appropriate?
No
Yes
No
Is it the only
option?
Cost-effective analysis
Yes
Fund
Yes
Is it cost
effective
?
Analysis
deferred?
No
No
Professional
or Patient
preference?
Yes
Procedure
analysis
Yes
7
Building the proposed MCDA
• Various criteria listed and arranged in a hierarchical,
priority-setting manner
• Dental procedure must satisfy all listed decision
criteria to be funded
– Fails to meet criterion definition  flagged not to be
funded
– Lacks evidence  considered for evidence-based review
8
Procedure
Program Objectives Analysis
Are program
objectives met?
No
Yes
Analysis against need
Is procedure needed?
No
Yes
Analysis against effectiveness
Is procedure
effective?
No
Yes
Analysis against appropriateness
Is procedure
appropriate?
No
Yes
9
Program Objective Analysis
• Procedure should:
– Reflect on the founding principles of the
program
– Support the ultimate goals or programs
objectives
– Preserve the sustainability of the program
10
Need Analysis
• Instrumental aspect of “need”
• Not linked to ill health
• “Minimum amount of resources required to
exhaust capacity to benefit” (Culyer and Wagstaff, 1993)
• Some needs ought to go unmet to be equitable
(Culyer , 1998)
11
Effectiveness Analysis
• Achieved its outcome in real life setting
(Guindo, 2012)
• Strength of evidence for evidenced-based decision
(Schanschieff , 1986)
• How much improvement after the procedure is
provided (Lavis, 1996)
• Basis for ‘Approppriateness’ (Lavis, 1996)
12
Appropriateness Analysis
• Effective for a particular patient or population
• No efforts are made to balance benefits and costs yet
(Lavis, 1996)
13
Cost-effectiveness Analysis
• Identify worth financing services from other options
(Johnson et al., 2009)
• Simplest criterion
• Last in the hierarchy (Musgrove, 1999)
• Other options for public funding (Musgrove, 1999)
14
Professional / patient
preferences Analysis
• Further analysis to avoid resource overutilization
• Individual welfare is not for the scope of social
responsibility (Wikler, 2002)
15
Procedure
Program Objectives Analysis
Are program
objectives met?
No
Yes
Analysis against need
Is procedure needed?
No
Yes
Analysis against effectiveness
Is procedure
effective?
No
Yes
Analysis against appropriateness
Is procedure
appropriate?
No
Yes
16
Do not fund
No
No
Yes
Only
option ?
No
Cost-effective analysis
Yes
Yes
Yes
Fund
Analysis
deferred?
Cost
effective ?
No
Professional
or Patient
preference?
Yes
Procedure
analysis
17
Strengths
• Systematic and evidence-informed tool
• Rational and transparent decision-making
process
• Identifies intrinsic values of each procedure
• Drives program performance according to
issues of sustainability
18
Weaknesses
• Resistance from service providers
• Resistance from funders
• Centralized administration
19
Conclusion
• Inequality in access to dental care as a public health
issue
• Sustainability of dental public health programs
• Maximize health benefits as an ethical objective of the
health care system
• Proposed systematic tool
– Evaluate current public oral health programs against their
strategic goals
– Push towards a stronger policy which includes vulnerable
populations other than children
20
Thank You!
21
References
•
Culyer AJ. The morality of efficiency in health care — some uncomfortable
implications. Health Econ 1992; 1: 7-18.
•
Culyer, A. Need-is a consensus possible? J. Med. Ethics 24, 77-80 (1998)
•
Elshaug, A., Moss, J.R., Littlejohns, P., Karnon, J., Merlin, T.L.& Hiller, J.E. (2009)
Identifying existing health care services that do not provide value for money. MJA
190, 5: 269-73.
•
Elshaug, A. G., Watt, A. M., Mundy, L. & Willis, C. D. Over 150 potentially low-value
health care practices: an Australian study. Med. J. Aust. 197, 556-560 (2012)
•
Garner, S. & Littlejohns, P. Disinvestment from low value clinical interventions:
NICEly done? BMJ 343, d4519 (2011)
22
References
•
Guindo, L. A. et al. From efficacy to equity: Literature review of decision criteria for resource
allocation and healthcare decisionmaking. Cost. Eff. Resour. Alloc 10, 9-7547-10-9 (2012)
•
Johnson, A. P. et al. Health technology assessment: a comprehensive framework for evidencebased recommendations in Ontario. Int. J. Technol. Assess. Health Care 25, 141-150 (2009)
•
Lavis, J. N. & Anderson, G. M. Appropriateness in health care delivery: definitions, measurement
and policy implications. CMAJ 154, 321-328 (1996)
•
Musgrove, P. Public spending on health care: how are different criteria related? Health Policy 47,
207-223 (1999)
•
Ontario Association of Public Health Dentistry (2005) Preparing for change, Retreat April 27 - 29, 2005.
Barrie: Vision Management Services, Ontario Association of Public Health Dentistry.
•
Quiñonez C, Sherret L, Grootendorst P, Shim MS, Azarpazhooh A, Locker D. An environmental
scan of provincial/territorial dental public health programs. Office of the Chief Dental Officer,
Health Canada. (2007) http://www.fptdwg.ca/English/e- environmental.html
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References
•
Schanschieff S. Report of the committee of enquiry into unnecessary dental
treatment, H M Stationery Office, Great Britain Department of Health and Social
Security, England, 1986
•
Wikler, D. Personal and social responsibility for health. Ethics Int. Aff. 16, 47-55
(2002)
•
World Health Organization (2004): Guidance on ethics and equitable access to HIV
treatment and care. http://www.who.int/ethics/Guidance%20on%20Ethics%
20and%20HIV.pdf.
•
Xie, F. et al. Using health technology assessment to support evidence-based
decision-making in Canada: an academic perspective. Expert Rev. Pharmacoecon
Outcomes Res. 11, 513-521 (2011).
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