| Comprehensive framework applying economic and ethical principles to ensure process is as fair as possible while simultaneously considering value within available resources (Mitton et al., 2014) | Decision-makers not having budget authority over full spectrum of services, thus making systemwide reallocation or trade-offs challenging (Mitton and Donaldson, 2004) |
| Explicit criteria and formal proposal scoring tool, including clearly defined and weighted criteria to guide relative value trade-off decisions (Wilson et al., 2007). By measuring the expected impact of any possible trade-off with the criteria, an organization measures the extent to which a given trade-off moves it toward or away from its mission and objectives | Budgets that are simply a roll-over of the previous year, adjusted for cost increases and population changes, with no real assessment of relative value and ad hoc threshold ICER approaches |
| Transparency in the process of decision-making coupled with stakeholder engagement; both of these pieces are key drivers for process fairness, which in turn results in credible results that are acceptable to key stakeholders (Jan, 2003) | A lack of transparency in regard to the actual elements that guide decisions and who influences the process and further a lack of support for process-based recommendations by those bearing the financial risk, leading to a lack of buy-in by politicians or higher-level decision-makers (Waldau, 2015) |