Transcript Health Technology Assessment

Health Technology Assessment
Perspectives and Trends
Abdulkadir Keskinaslan, MD, MBA, MPH
Market Pricing Director Asia Pac
29-31 Oct 2009, Kapadokya, Turkiye
Health care spend has reached USD 3.5 trillion in OECD
Providers and distributors account for 66% followed by 17% for pharmaceuticals
2005 Revenue, Health Care Industry1
USD billion (nominal)
Publicly traded companies
Government & Non-profit
Share of HC total
OECD
10%
66%
2,364
17%
343
47
296
5%
171
2%
<1%
70
25
592
3,565
1,843
1,797
1,722
567
Providers/
Distributors
Pharmaceuticals
Payors/
PBMs
Devices/
Equipment
Biotechnology
Other
Note: Includes non-profit hospitals and services and government-owned hospitals and service providers; OECD countries only;
1 Conservative estimates considering only OECD countries
Source: McKinsey analysis; OECD, IMS
2
Total
Demographic transition will be the leading cause of
growth in health care spend
 Global population ageing – decreasing fertility
along with lengthening life expectancy shifting
relative weight from younger to older groups
 Regional differences in life expectancy at
birth are expected to decrease – an
interregional gap of about 7 years is expected by
2045-2050, down from approximately 9 years in
the period 2025-2030 and from almost 12 years
at present
Source: Lesthaeghe. 2000; WHO. World Population Ageing 1950-2050
3
Shift in burden of disease into specialty areas - oncology and
neuroscience - will increase demand for services
1993
Other
Musculoskeletal
Injuries
Diabetes
Chronic respiratory
Mental
Neurological
Cardiovascular
Cancer
200
0
0
20
40
400
Number (thousands)
400
2023
Age
200
60
80
100
0
0
Australia 1993–2023
Source: Carter R. Presented at HTA Workshop in Beijing 2008
Referencing Begg S. 2008 also available at
http://www.aihw.gov.au/bod/index.cfm
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20
40
Age
60
80
100
Higher per capita health expenditure for elderly will further
increase
9000
8000
Male
Female
per capita expenditure
7000
6000
5000
4000
3000
2000
1000
0
0-4
5–14
15–24
25–34
35–44
45–54
Australia 2000-2001
Source: Carter R. Presented at HTA Workshop in Beijing 2008
Referencing Data from: AIHW (2005) Health system exp. on disease
and injury in Australia, 2000-01. AIHW Cat No HWE 28
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55–64
65–74
75+
Health care spend has grown above GDP
Health care spend
Percent of GDP, 1960–2006
16
14
Health care spend
as percent of GDP
12
10
8
6
4
2
0
1960
1970
1980
1990
2000
2010
Health care expenditure/capita in USD 000, PPP, 2005;
Source: Source: OECD Health Data 2008, McKinsey
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Growth
in percent
share of
GDP,
CAGR
1960
2006
5.1%
15.3%
2.4%
4.9%
11.3%
1.8%
6.0%
10.6%
1.2%
3.9%
8.4%
1.6%
Health care spend as % of projected GDP will keep growing
Australia 2003-2033
% GDP
12.0
10.0
10.8
9.9
9.4
10.1
9.2
9.0
7.9
8.0
9.9
6.8
5.7
7.9
6.0
6.2
4.0
5.1
4.7
2.0
0.0
2003
2013
2023
2033
2043
UoQ/AIHW (All health expenditure, including private sector
Inter-Generational Report: Federal Govt expenditure only
Productivity Commission (State & Federal Govt – no private expend)
Source: Carter R. Presented at HTA Workshop in Beijing 2008
Referencing Data from: Begg S. 2008
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Health care strategy is all about how you spend your money
UK is about 5 times more productive than US in managing Type II Diabetes
 Disease burden (DALYs)
 Per
100,000 population
449
340
267
232
 Productivity*
 x5.0
5.0
3.0
 Diabetes expenditure
 USD per diabetic person
2.4
1.0
6,231
4,430
2,713
2,431
* Productivity as performance index is calculated as product of DALY and per capita total expenditure on
health, normalized with value of US as 1.0. For country X, (DALY*Cost in US) /(DALY*Cost in Country X)
Source: WHO GBD Report 2009; International Diabetes Federation - Diabetes Atlas, ADA, NHS 8
Health Care needs drive changes pricing and value
assessment
Pricing
Hypothesis
Innovative agreements will
become a more common
and accepted approach
Comments
 Innovative pricing models help industry and countries offer access for
affordable medicine to appropriate patients
 The UK, Australia and Germany are more advance in offering
 Patients are needing to pay more – as full cash payers or in the form of
copays – and demanding more
Health care cost will be
shifted to patients
 Tends to rewarded adherent patients with services and lower premiums
in the US
Assessing Value
 In Turkey there are growing trends towards contribution to treatment
Reimbursement will be
informed by Health
Technology Assessment
 HTA used to assess the most appropriate population to benefit
 Reimbursement can be conditional or increased on the provision of
additional evidence
 Restriction of reimbursement to subgroups of patients in which the
price is justified
Comparative effectiveness
will be used to evaluate
value
 Providers may be asked for comparative data even post registration
 Cost effectiveness evaluations will take into account all costs, not just
those of drugs, providing room for cost-offset arguments
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Risk pooling empowers budget holders shifting inelastic
demand towards elasticity
DEMAND CURVE:
Inelastic,
Unitary Elastic,
Elastic,
n = -1
Price elasticity of demand:
responsiveness in the quantity
demanded as a result of change
in price
elastic if consumers will only
pay a narrow range of prices
– sugar
inelastic if consumers will pay
almost any price for the product
– water
Price
Perfectly inelastic demand:
changes in the price do not
affect the quantity demanded for
the good
Need for heart for transplant –
no matter what the price is a
person needs one
Inelastic
Unitary
Elastic
Elastic
Budget Impact
D
Relatively inelastic demand:
when the change in quantity
demanded is less than change
in price
Need for an antibiotic for a
resistant bacteria
Quantity
?
=
Price negotiations through risk pooling helps inelastic demand shifted towards elastic
Demand from an insurance fund holder for 100 transplant a year
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Performance Oriented Models
Value Based – Risk sharing pricing framework
Financial
contracting
models
Outcomes based
models
Risk based
models
Consumer
oriented models
• Reimbursement / pricing through financial arrangements
- Price-volume agreements
- Dynamic benefit schemes (rebate depending on market share targets)
- Patient capitation and dose caps
• Different reimbursed price depending on
patient outcomes
- treatment response
- treatment outcome
• Different reimbursed price depending on
patient sub-groups
- by indication
- treatment history
- risk factors
• Implementing differentiated pricing models
by providing direct benefits to patients
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Innovative Pricing approach help create win-win solutions
Underlying goal of models similar, but differ in reimbursement price and scheme
Financial Contracting
Models - Utilization
Initial 10% of patients
Outcomes Based
Pricing Models
Full response
Next 20% of patients
High Risk
Partial response
All others
Patient segments
Risked Based
Pricing Models
Moderate risk
No response
Patient segments
 Price Volume Agreement: e.g.
 Money back guarantee, e.g.
full reimbursement for first
10% of patients, reduced
reimbursement for next 20%
of patients, no reimbursement for all others
full reimbursement for
responders, reduced
reimbursement for partial
responders, no reimbursement for non-responders
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Low risk
Patient segments
 Reimbursement linked to
value and level of risk (e.g.
based on diagnostic test)
What is TA?
 Technology Assessment (TA) is a concept, which embraces different forms of policy analysis on the
relation between science and technology on the one hand, and policy, society and the individual on
the other hand. Technology Assessment typically includes policy analysis approaches such as
foresight; economic analysis; systems analysis; strategic analysis etc. TA could make policy analysis
about:
The energy situation
Globalisation and labour
market competences
Privacy in e-government
Potential of
nanotechnology in
health care
Working conditions in
the light of increasing
ICT work
GMO and
environment
Technology Assessment has three dimensions
•The cognitive dimension - creating overview on knowledge, relevant to policy-making
•The normative dimension - establishing dialogue in order to support opinion making
•The pragmatic dimension - establish processes that help decisions to be made
And TA has three objects
•The issue or technology
•The social aspects
•The policy aspects
Sources:http://www.eptanetwork.org/EPTA/what.php
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From TA to HTA
 1967 - Technology Assessment first used in the Subcommittee on Science, Research, and
Development of the House Science and Astronautics Committee of the U.S. Congress
 1972 - the U.S. Congress created the The Office of Technology Assessment (OTA) by Public Law
92–484. OTA provide analysis of the complex scientific and technical issues from 1972 to 1995
 1987 - Scientific Technology Options Assessment (STOA)-an official organ of the European
Parliament – started releasing reports partnering with external experts.
 1990 - The European Parliamentary Technology Assessment Network-EPTA was formally
established under the patronage of the President of the European Parliament to advise parliaments
on the possible social, economic and environmental impact of new sciences and technologies. E.g.
Working in future - structures and trends in industrial work , Vaccine capacity in the UK.
 In 1973-1975 roots of Health Technology was established:
• the U.S. Academy of Sciences published a report that examined the implications of four health technologies: in vitro
fertilization, choosing the sex of children, retardation of aging, and modifying human behavior
• The National Institutes of Health carried out a rather comprehensive assessment of the totally implantable artificial
heart in 1973
• The Swedish Organization, Spri, carried out a cost-effectivenessanalysis of the computed tomography (CT)
scanner (the first HTA outside of the US)
Sources: Banta. 2009;
www.eptanetwork.org/EPTA/about.php;
www.europarl.europa.eu/stoa/default_en.htm
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Health Technology Assessment is a tool for Decision Making
and Priority Setting at Given Resources
Policies no longer focused solely on cost-containment,
but achieving value for money
Health Technology Assessment - HTA
 HTA studies the medical, social, ethical, (legal) and economic implications of development, diffusion
and use of technology and informs policy decision
 Its aim is to improve quality and cost-effectiveness of healthcare
Health Technology
 Health technology covers any method (intervention) used to promote health, prevent and treat
disease and improve rehabilitation or long-term care
Pharmaceuticals
Surgical procedures
Medical Devices
Preventive
Programme
Rehabilitation
Programme
Health Services and
Health Systems
Sources: Adapted from http://www.singhealth.com.sg/
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Criteria for HTA varies based on country perspective
Criteria
AT
BE
CH
DE
FI
FR
NL
NO
SE
UK
Therapeutic benefit
X
X
X
X
X
X
X
X
X
X
Patient benefit
X
X
X
X
X
X
X
X
X
X
Cost-effectiveness
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Budget impact
Pharmaceutical/innovative
characteristics
X
Availability of therapeutic
alternatives
X
X
X
Public health impact
X
R&D
Sources: Sorenson 2008
X
X
Equity considerations
X
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X
X
X
X
X
Increasing interest in HTA across Asia Pac
following trends in the US and Europe
Formal HTA programs
Country – HTA
HTA Body since
 Non-Pharmaceuticals - the Medicare Services Advisory Committee (MSAC)
since late 1998
Australia – MSAC, PBAC
 Pharmaceuticals - the Pharmaceutical Benefits Advisory Committee (PBAC)
Mandatory economic evaluation since 1993
 The Australian Safety and Efficacy Register of New Interventional
Procedures—Surgical (ASERNIP-S) since 1998
 HTA at state government level within public hospitals
New Zealand – NZHTA
 New Zealand Health Technology Assessment (NZHTA) since 1997
 An agency of the National Health Insurance (NHI), the Health Insurance
South Korea – HIRA
Thailand – HITAP
Taiwan – CDE
Review and Assessment Service (HIRA) is responsible for working-level
benefit determination since 2000
 HTA Center within HIRA was tasked to perform HTA in 2007
 Plans to introduce new national independent organization for HTA and based
on the model of the NICE of the UK
 Health Intervention and Technology Assessment Program (HITAP) was
established in 1996
 HTA is actively used for policy decisions
 Center for Drug Evaluation (CDE) - HTA division since 2007
Source: Hailey D. 2009; Sivalal S. 2009; Chang-yup Kim, 2009; Teerawattananon Y. 2009
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Key Principles for the Improved Conduct of Health
Technology Assessments for Resource Allocation Decisions
From Future Trends Workshop 2008-2009
1. The goal and scope of the HTA should be explicit and relevant to its use
2. HTA should be an unbiased and transparent exercise
3. HTA should include all relevant technologies
4. A clear system for setting priorities for HTA should exist
5. HTA should incorporate appropriate methods for assessing costs and
benefits
6. HTAs should consider a wide range of evidence and outcomes
7. A full societal perspective should be considered when undertaking HTAs
8. HTAs should explicitly characterize uncertainty surrounding estimates
Source: Sullivan S. Future Trends Workshop, Seoul 2008, Singapore 2009, Drummond 2008
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Key Principles for the Improved Conduct of Health
Technology Assessments for Resource Allocation Decisions
9. HTAs should consider and address issues of generalizability and
transferability
10. Those conducting HTAs should actively engage all key stakeholder groups
11. Those undertaking HTAs should actively seek all available data
12. The implementation of HTA findings needs to be monitored
13. HTA should be timely
14. HTA findings need to be communicated appropriately to different decision
makers
15. The link between HTA findings and decision making processes needs to be in
all transparent and clearly defined
Michael F. Drummond University of York, J. Sanford Schwartz University of Pennsylvania, Bengt
Jonsson Stockholm School of Economics, Bryan R. Luce United BioSource Corporation, Peter J.
Neumann Tufts University, Uwe Siebert UMIT—University for Health Sciences, Medical Informatics
and Technology, Sean D. Sullivan University of Washington; International Journal of Technology
Assessment in Health Care, 24:3 (2008), 244–258.
Source: Sullivan S. Future Trends Workshop, Seoul 2008, Singapore 2009, Drummond 2008
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Key Principles for Improved Health Technology Assessment:
Identify and inform organizational, procedural and methodological best practice
Australia (PBAC), Brazil (ANVISA), Canada (CADTH), Germany (DAHTA@DIMDI,
IQWiG), Korea (HIRA), Sweden (TLV, SBU), Taiwan (CDE), the United Kingdom (NICE),
and United States (Blue Cross/Blue Shield, CMS, DERP, Wellpoint).
 Many of the organizations support and implement certain principles, such as
being explicit about their HTA goals and scope; considering a wide range of
evidence and outcomes; and seeking all available data
 Other principles, such as taking a full societal perspective; having a clear
system for setting priorities; explicitly characterizing uncertainty surrounding
estimates; monitoring the implementation of HTA findings; and considering the
generalizability and transferability of results receive much less backing
 There is also variation in the degree to which organizations incorporate
appropriate methods for assessing costs and benefits
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Source: Sullivan S. Future Trends Workshop, Singapore 2009; Neumann 2009 accepted for publication
HTA systems: room for improvement
 HTA’s role and utility in decision-making and priority-setting of health care
systems and impact on innovation
 Risk of using HTA as a cost-containment measure
 HTA governance including transparency, accountability and stakeholder
involvement in the HTA process
 Stakeholder agreement on methods, evidence requirements and costeffectiveness thresholds employed during the assessment process
 Delays in the HTA process restricting patient access to treatments
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Discussion points
Issues? Resources? Knowledge Networks?
 Despite the fact that Turkey is advanced on the equity dimension in Health
Care, HTA has been relatively slow in gaining much of a foothold. What are the
factors that play role in this? Political support? Capacity? Investment?
 How to speed up capacity building in Turkey? Human resources? Resources in
general? Network? What should be the role for stakeholders in capacity
building?
 What is the potential value of Information Centers and Knowledge Networks?
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Information Centers and knowledge networks for HTA
can accelerate collaboration
 International Network of Agencies for Health Technology Assessment (INAHTA)
• Accelerate exchange and collaboration among agencies
• Promote information sharing and comparison
• Prevent unnecessary duplication of activities.
 HTA on the net; A Guide to Internet Sources of Information from Institute of Health
Economics is a toolkit with links
• specialized bibliographic databases relevant to the subject of the assessment;
• data from government and regulatory agencies;
• administrative databases;
• industry studies, and advice from experts in the field
 NHS Economic Evaluation Database (NHS EED): published economic evaluations of
health care interventions
Source: http://www.inahta.org/HTA/
http://www.ihe.ca/publications/library/2008/health-technology-assessment-on-the-net-10th/
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