Health Technology Assessment and evidence-informed decision making

Derek Cutler, MScNICE International

Burden of chronic

disease and ageing

populations

Users’expectations

and the promise of universal

coverage

Growth in technologies –

expanding marketplace

Finite budgets and financial

pressures

Policy and practice

Health systems everywhere are

under pressure…

We cannot afford everything that is clinically effective

“The NHS, just like every other healthcare system in the world—public or private—has to set priorities and make choices. The issue is not whether there are choices to be made, but how those choices are made. There is not a service in the world, defence, education or health, where this is not the case.”

UK Parliamentary Health Committee

Payers’ responses• Accumulating debt

• (Arbitrary) price cuts

• Divergence between coverage (in principle) and access

• Cost-shifting to service users and their families

• Price negotiations

• Risk sharing and Value-Based Pricing

• ‘Institutionalising’ technology adoption decisions: Health Technology Assessment agencies

• A combination of the above…

What is Health Technology Assessment?

“A multi-disciplinary field of policy analysis that examines the medical, economic, social and ethical implications of the incremental value, diffusion and use of a medical technology in health care.”

Medical technology: “Any intervention that may be used to promote health, to prevent, diagnose or treat disease or for rehabilitation or long-term care. This includes pharmaceuticals, devices, procedures and organizational systems used in health care.”

INAHTA (International Network of Agencies for Health Technology Assessment)

HTA as a tool• HTA can help policy makers to:

– effectively prioritise health interventions and services

– improve their quality– make consistent decisions– reduce inappropriate variation– signal ‘value’ to industry– inform the selection of indicators to assess

performance and incentivise providers, especially in the context of capitation

HTA as a tool

• Not a ‘cure all’ for all system inefficiencies and problems

• But, combined with inclusive, transparent processes can confer legitimacy on decisions

• Particularly important in the case of ‘no’ decisions and saving money to reinvest and to expand coverage

HTA audiences

• Policy-makers - payers• Medical products developers – industry• Healthcare professionals• Academic community - researchers• General public: taxpayers; insured population;

informal sector• Patients and their families• NGOs / third sector• Donors

Dimensions of HTA

• Comparative clinical effectiveness

• Comparative cost-effectiveness

• Service delivery organisation aspects

• Legal framework

• Ethical, social implications – equity, fairness and other societal norms

Comparative clinical and cost-effectiveness

1. How well does the technology/intervention work compared to standard practice in OUR healthcare system? Health gain can be estimated using quality adjusted life years (QALYs)

2. How much does the technology/intervention cost compared to

standard practice in OUR healthcare system?•cost of technology, monitoring, length of inpatient or outpatient stay, costs of treating adverse events

3. Incremental cost effectiveness can be calculated by comparing (1) and (2)

Difference in costs

Difference in effect

Role of cost effectiveness in NICE guidance

• “Those developing clinical guidelines, technology appraisals or public health guidance must take into account the relative costs and benefits of interventions (their ‘cost effectiveness’) when deciding whether or not to recommend them.” (Principle 2, Social Value Judgements, NICE 2008)

BUT

• “Decisions about whether to recommend interventions should not be based on evidence of their relative costs and benefits alone. NICE must consider other factors when developing its guidance, including the need to distribute health resources in the fairest way within society as a whole.” (Principle 3)

Cost-effectiveness and…

ADVISORY GROUPDECISIONS

ADVISORY GROUPDECISIONS

Non-utilitarian criteria: ethics, equity, rights

Non-utilitarian criteria: ethics, equity, rights

Legal and policy

constraints

Legal and policy

constraints

Practicalities of implementation

Practicalities of implementation

Extent of uncertainty

Extent of uncertainty

Cost-effectiveness

Cost-effectiveness

NICE PrinciplesKey procedural principles

Independence from government, industry, individual professional and patient groups

Transparency: guidance products and methods are a public good; peer review of methods and of products

Timeliness to meet the needs of a changing healthcare system

Consultation with all those affected by the decisions and direct engagement with individuals and organisations

Scientific rigour in methods for guidance production and appropriate use of the best available evidence

Contestability of decision making process through appeal mechanisms and right to legal challenge

Process

Process matters

Open, consultative decision-making processes:

•Confer legitimacy

•Improve the quality and relevance of decisions

•Protect against vested interests and bias

Local institutions matter

“Successful development depends to a large extent on a government‘s

capacity to implement its policies and manage public resources through its

own institutions and systems”

The Paris Declaration on Aid Effectiveness (2005) and the Accra Agenda for Action (2008)

“Successful development depends to a large extent on a government‘s

capacity to implement its policies and manage public resources through its

own institutions and systems”

The Paris Declaration on Aid Effectiveness (2005) and the Accra Agenda for Action (2008)

Institutions: International Examples

• PHARMAC, New Zealand• IQWiG / GBS, Germany• NICE, UK• PBAC and MSAC, Australia • IETS, Colombia• HIRA/NECA, S Korea• AHTAPol, Poland• CADTH, Canada• MOH/GNDP/NHIS, Ghana• HITAP, Thailand

• Locally-led HTA-informed decision making requires:

• Technical capacity– Systematic reviews / meta analysis

– Health Economics

• Political backing

• Starting to do HTA can be a means of building and reinforcing such capacity. Example: Technical capacity at UK universities

Building capacity

Building capacity: HTA and policy-making: a symbiotic relationship?

1. Academics in the field of HTA driving policy

2. Policy makers driving academic HTA research

Result: Increased • knowledge • capacity • impact

in both areas

Need for HTA:

What policy decisions will be informed by HTA?

Demand for HTA

Who (departments, institutions) will be using the outputs of

HTA?

Supply of HTA:

Who (departments, institutions) will be conducting HTA and running the HTA

process?

Need, demand, and supply are different in every country:

Summary• HTA: a useful tool for policy makers to assess the

value of a range of health technologies, including drugs, medical devices and disease prevention interventions; and help maximise the impact of finite healthcare budgets

• A means of legitimising disinvestment decisions, and saving money to reinvest and expand coverage

• Countries starting out in HTA should not wait for ‘full’ capacity to do HTA, but rather concentrate on using the policy need to drive capacity building

Some implications for Ghana

• HTA may be a useful tool for Ghanaian decision-makers in achieving their joint aims of expanding coverage, increasing care quality, and ensuring financial sustainability

• Inclusive and transparent processes will be important in managing political tensions and ensuring the legitimacy of decisions

• Ghana has well-developed institutions which could inform and contribute to such activity – important to build on these.

• Need to consider who should convene and drive the process