My challenge to each of us is
Transcript of My challenge to each of us is
My challenge to each of us is …
collaborate
for the benefit of all New Zealanders!
Anne Kolbe ONZM, MBBS (Hons), FRACS, FRCSEng (Hon), FCSHK (Hon), FRCSEd (Hon), MAICD
Chair, New Zealand National Health Committee
NHC MTANZ 2014
Declarations of Interest
• Vocationally registered paediatric surgeon
• Chair, National Health Committee
• Co-chair, international Policy Group G2MC
• Director, Pharmaceutical Management Agency
(PHARMAC) 2010 - 2013
NHC MTANZ 2014
My responsibilities today …
• Set the scene
• Discuss the NHC’s approach to the
management of technology with an
emphasis on business and finances
• Dispel some myths
• Encourage collaboration and cooperation
for the good of all
NHC MTANZ 2014
Vote: Health $15 billion
DHBs
Disability
Education
Public Health
Primary Health
Maternity
Ministry
NHC MTANZ 2014
Growth in core Crown health spending has outstripped national income...
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Health: 412%
GDP: 144%
% change since 1950
Core Crown health expenditure per capita and GDP per capita (indexed real growth)
Growth in core Crown health spending has
outstripped national income … Core Crown health expenditure per capita and GDP per capita indexed real growth
This has major implications for organising health and long term care
• Systems evolved to manage acute (e.g. infectious), life-threatening conditions
– care tended to be episodic, reactive, delivered by individual professionals
– emphasis on hospitals & doctor-led care organised around medical specialties
– patients were seen as passive rather than contributors to their own care
• Even systems with strong emphasis on LTCs suffer from variations in quality, weaknesses in coordination, unplanned hospital admissions
Nicholas Mays, London School of Hygiene and Tropical Medicine, Affording Our Future
Wellington, December 2012 NHC MTANZ 2014
Nicholas Mays, London School of Hygiene and Tropical Medicine, Affording Our Future
Wellington, December 2012
This has major implications for organising health and long term care
• Systems evolved to manage acute (e.g. infectious), life-threatening conditions
– care tended to be episodic, reactive, delivered by individual professionals
– emphasis on hospitals & doctor-led care organised around medical specialties
– patients were seen as passive rather than contributors to their own care
• Even systems with strong emphasis on LTCs suffer from variations in quality, weaknesses in coordination, unplanned hospital admissions
Projected change in composition of govt expenditure (excl. financing)
Health
Superannuation
Education
Other
Non-NZS welfare
21%
31%
2010
2060
NHC MTANZ 2014
Drivers of sector expenditure
• Labour Price Index
• Commodities Price Index
• Deficit Funding
• New Policy
• Demographics
• Technology
NHC MTANZ 2014
National Health Committee
Section 11 advisory Committee responsible for providing the Minister of Health with evidence based recommendations on:
• Which technologies should be publicly funded in New Zealand
• To what level and where technology should be provided
• How new technology should be introduced and old technology removed
NHC MTANZ 2014
NHC uses the WHO definition of technology
with a focus on models of care
Components of a model of care
• Pathway of care for 80% of target patient
population
• Business model that supports and manages
the resource critical nodes in the pathway of
care
NHC MTANZ 2014
What are we trying to achieve?
• Safe, quality, measurable health,
wellbeing and independence
outcomes for individual patients and
populations
• Value for money and affordability
• Sustainability
• Contribute to GDP growth
NHC MTANZ 2014
Value for money (VfM) and
affordability
measurable health outcomes
VfM
cost of the resources invested
in the model of care
NHC MTANZ 2014
Nicholas Mays, London School of Hygiene and Tropical Medicine, Affording Our Future
Wellington, December 2012
This has major implications for organising health and long term care
• Systems evolved to manage acute (e.g. infectious), life-threatening conditions
– care tended to be episodic, reactive, delivered by individual professionals
– emphasis on hospitals & doctor-led care organised around medical specialties
– patients were seen as passive rather than contributors to their own care
• Even systems with strong emphasis on LTCs suffer from variations in quality, weaknesses in coordination, unplanned hospital admissions
Sustainability
Continuing to provide the range and
types of services (outcomes) currently
available, or better, without incurring
excessive levels of taxes and / or debt
NHC MTANZ 2014
NHC approach …
• Evidence based, management of non-drug
technologies with a focus on models of care
• Four domains
• Clinical safety and effectiveness
• Societal and ethical
• Economic
• Feasibility of adoption
• 11 decision making criteria
• A4R framework
NHC MTANZ 2014
NHC Strategic Business Plan
technology management streams and tools
• Proactive
• Reactive
• Pull model
• Sector Programme Budget
• Tiered business cases
• Notional Budget
• Sector annual referral round
• Innovation fund, HRC &CI
Streams
Tools
NHC MTANZ 2014
Programme Budget 2013 NHC analysis of 2010–2013 NMDS
Source; NHC Strategic Business Plan 2014/15-17/18
FINAL June 2014 15
Figure 5: Size and price of New Zealand public hospital disease burden, 2012/13
Source: 2013 NHC analysis of 2010–2013 NMDS
3.3 Measuring the bend in the cost curve
3.3.1 QALY and DALY measures
The traditional approach to managed diffusion of technology through a health system is to undertake
a detailed health technology assessment of a single technology in isolation and to measure the
outcome in QALYs or DALYs (Quality Adjusted Life Year or Disability Adjusted Life Year). Most HTA
agencies internationally follow this path and will recommend the introduction of a technology that
generates a benefit in local currency of less than or equal to 15,000–30,000 per QALY. The difficulty
with this approach is that its slow speed means it cannot keep pace with the volume of technology
being introduced. Its isolation also means it does not test the comparative effectiveness of the
technology against other new or existing interventions or the best fit of the technology into a model of
care. Therefore, the health system may invest in an effective, but comparatively inefficient technology
and the cost curve will not be bent to maximum effect, limiting the choices for investment elsewhere.
The risks of the traditional methodology are increasing as many new technologies have higher up-
front costs than has traditionally been the case. New Zealand is moving to reduce this risk by
implementing “mega analyses” whereby the NHC undertakes an assessment of a basket of
technologies used to treat a particular disease state(s)/ service linked to a pre-selected heath status.
The NHC then recommends implementation of the most cost effective mix of interventions across a
model of care.
The NHC will continue to implement the mega analysis approach through its tiered business case
model. Focus areas are outlined in section 5 of the four year strategic business plan.
Mean%Price%($1000s)
Individuals%(n,%thousands)
Ministry of Health 8/4/14 1:05 PM
Deleted: As an interim step the Committee intends to act on (and refine and extend) the cluster of cardiology related referrals the
sector sent to it for consideration for health technology assessment during 2012/13. This course of action will enable it to reflect
sector concern about the push for investment within the specialty while at the same time developing expertise in one of
the areas its own work has identified as being amongst the top three fast growing health spends – making it an ideal candidate
for the initial development of the pull model.... [6]
Ministry of Health 4/4/14 4:34 PM
Deleted: 1
Ministry of Health 4/4/14 4:36 PM
Deleted: <#>Figure 2, Size and price of New Zealand admitted and non-admitted
health system burden, 2011/12 ... [7]
Ministry of Health 2/6/14 10:28 PM
Deleted: pathway
Ministry of Health 4/4/14 4:38 PM
Deleted: Ontario, Canada
Ministry of Health 4/4/14 4:38 PM
Deleted: its HTA agency, the Ontario Health Technology Assessment Committee (OHTAC),
Ministry of Health 4/4/14 4:38 PM
Deleted: OHTAC
Ministry of Health 4/4/14 4:39 PM
Deleted: In New Zealand t
Ministry of Health 4/4/14 4:39 PM
Deleted: through an assessment of respiratory medicine (chronic obstructive pulmonary
disease, COPD) and a further investigation of cardiac interventions (ischaemic heart disease, IHD).
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NHC Business Plan 2013/14
9 Commercial In Confidence
Figure 2: NHC Tiered Approach for Prioritising Work Plans/Seeking Advice and Engaging with the Health Sector
Source: NHC Executive
1.1.4. Providers – DHBs, NGOs and Private
The bulk of the work and risk associated with implementing NHC recommendations sits with sector
providers. The NHC will remain closely aligned to sector thinking in order to be successful in
improving New Zealand’s uptake of health technology. On-going engagement and participation at
a governance and executive level will be necessary. This will be reflected by:
· the composition of the Committee itself
· the NHC facilitating the development of regional prioritisation networks whose work
will benefit and inform that of the national committee
· the running of a distributed executive model with offices in Auckland and Wellington
· alignment with financial planning, funding and budgeting processes
· Ensuring close involvement in the development of NHC business cases through the
tiered approach to ensure feasibility of adoption of the NHC’s recommendations.
Ministry of Health 11/10/13 9:30 AM
Deleted: these agencies are
Ministry of Health 11/10/13 9:30 AM
Deleted: d
Ministry of Health 11/10/13 9:30 AM
Deleted: NHC working groups
NHC Tiered Business Approach to Work Plans
Sector Engagement and Participation
Source; NHC Strategic Business Plan 2014/15-17/18 NHC MTANZ 2014
5
Figure 1: NHC Workflow Diagram
Source: Source; NHC Strategic Business Plan 2014/15-17/18 NHC MTANZ 2014
Basic Research Clinical Trials Field and Innovation Evaluations
HRC HIP CI NZTE
NHC
T Phase 1 2 3 4
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NHC MTANZ 2014
!!
Global&Market&
!
The&Missions&National&Health&Committee&(NHC)& &
·
·
·
Callaghan&Innovation&
·
·
·
The&Opportunity&&
easier New&Zealand&firmscommercialise new
technologies&and&services
·
growth&potential
· fair value
· inventiveness attractiveness
· safe
The&Unique&Assets&National&Health&Committee&(NHC)&
·
·
·
·
Callaghan&Innovation&
·
·
·
·
Together&
·
·
·
Research&Community&
Firms
Assessment&Gatekeepers&
· NHC&
·
Domestic&Market&&
&&
How&do&we&make&this&process&easier?&
Callaghan&Innovation&
National&Health&Committee&
CMDT%
THE!NHC’s!model!of!forecast!“significant!and!fast!growing!spend”!becomes!a!signaling!device!for!current!research!priorities,!and!informs!support!policies!!!
The!NHC’s!Innovation!fund!validates!technology!through!clinical!trials!(HRC!methodologies)!designed!to!maximize!value!to!firms’!global!commercialisation!efforts,!but!in!ways!that!keep!NZers’!safe.!!
Terms!of!agreement!with!firm!structured!to!capture!future!to!NZ!!!
Next&Steps&
·
·
·
·
Explore!potential!to!expand!approach!more!widely,!including!expansion!to!PHARMAC!and!leveraging!of!the!HIH’s!
relationships!with!some!DHBs!!!
CI’s!National!Technology!Networks!and!leadership!
positions!in!other!research/firm!consortia!(such!as!the!CMDT)!are!effective!means!of!
engaging!with!the!research!community!and!shaping!research!priorities!!
CI’s!Business!R&D!grants!support!firm!lead!development!of!
technology!
CI’s!Business!Innovation!Advisors!support!firms!in!their!commercialization!journeys,!including!
business!planning,!capital!access!and!deQ!risking!and!increasing!the!market!potential!
Pipeline!of!emerging!technologies!can!be!mapped!and!monitored!against!the!NHC’s!emerging!and!
future!priorities!
Procurement%Gatekeepers%
· PHARMAC!· HBL%
Procurement%Gatekeepers%
· DHBs%
Intention!to!accommodate!the!joint!regulatory!agreement!with!Australia!(2016)!!
NHC MTANZ 2014
4 Committee Report to the Minister June 2014
Table 3: Example of a notional budget.
Portfolio
assessments Year 1 Year 2 Year 3
Total over
10 years
Health
Outcome
Measure (QALY / DALY)
Intervention A -$5m -$5m -$5m -$50m 10
Intervention B $10m -$12m -$12m -$96m 25
Intervention C -$10m $0m $0m -$10m 50
Intervention D $5m $10m $15m $135m 100
Total $0m -$7m -$2m -$21m
Source: NHC Executive
22. Table 3 demonstrates how a portfolio of assessments would work together to build a fiscally
prudent and sustainable notional budget. In this example, the NHC is creating $15 million in
savings in year one, which is offset by $15 million in new expenditure. This results in zero
additional expenditure in year one.
23. The zero year one expenditure impact outlined in Table 3 is only one of the possible
scenarios. For example a different portfolio might yield a net total savings in year one, which
would allow the NHC to bank or reallocate funds towards additional high value for money
investments. Net positive expenditure could occur with the approval of the Minister. Risk is
managed by the need for the notional budget to deliver a realistic forecast in order to work
appropriately.
24. In the example in Table 3, interventions A and B contribute savings to the sector in the out
years, which generates notional savings in the portfolio. Over time as the portfolio builds up
these savings become more significant.
25. The notional budget approach also illustrates how the NHC can offset expenditure in
interventions with upfront costs, but long run savings (Intervention B) or interventions which
are not cost saving, but provide good value for money health gains to New Zealanders
(Intervention D).
26. The example illustrates how the use of a notional budget would discourage new expenditure,
which is not offset by savings as the budget would no longer balance. In this way, the notional
budget also allows for the NHC to manage ‘investments’, where recommendations are net
cost increasing, but provide significant health benefits. In addition, the concept allows the
NHC to manage a balance between short run expenditure and long run savings.
27. A notional budget informs the amount of savings that would need to be found in a financial
year in order to balance new expenditure and savings, as well as short and long run
outcomes. This allows the NHC to align its work programme and resources in order to deliver
a material notional budget to the sector.
28. Balancing a notional budget alone does not incentivise a high volume of recommendations. To
create these incentives, it is recommended that the NHC continues to set a materiality target,
focusing on growing the size of the notional budget over time. As shown in Table 3 this should
also be aligned to health outcomes measures.
Example of a notional budget
Source: NHC Executive Notional Budget paper 2014
NHC MTANZ 2014
NHC budget management
• Released value (savings): cost effectiveness,
efficiencies and reprioritisation
• Wise investment (expenditure)
• Savings and expenditure:
• Notional and real
• Budget and non-budget
• Direct and indirect
NHC MTANZ 2014
Tier 1 Strategic Overview
Respiratory Disease in New Zealand
• $265m public casemix hospital discharges
• 10 disease states within respiratory disease
• prevalence, incidence, health outcomes, health utilisation and cost
Identify the disease state for Tier 2 assessment with the aim of improving health outcomes whilst maintaining or reducing costs through the prioritisation and application of the most cost effective new and existing health technologies across a model of care
Source: NHC Respiratory Disease in New Zealand
NHC MTANZ 2014
Respiratory Disease in New Zealand (Working Draft) 11
6 Pathway of Care
Whilst there are many variations of the specific details of a COPD pathway, all COPD pathways
follow the same basic principles of diagnosis and treatment. Figure 3 outlines the pathway of
care for COPD and the interventions that comprise that pathway. This pathway provides a
general picture of COPD care, but not every patient will travel through the pathway in the same
way nor will they receive the same interventions along the pathway of care.
Figure 3: Pathway of care for COPD
Source: Refer to Methods
NHC Model of Care for COPD 2013 NHC MTANZ 2014
5
Yes
No
Yes
No
Low, medium,
high
Very high
Yes
No Referred
Referred
High Frailty
Patient presents to
Primary Care with symptoms and/or
murmur
Seen in Cardiology
Outpatients (COPC)
Transthoracic Echo performed/reviewed
Transthoracic Echo performed by another
service e.g. General
Medicine, Geriatrics
Severe AS
confirmed
Frailty
Assessment1
No
Intervention
Palliative Care Primary Care
Investigations Coronary angiogram Femoral angiogram
Spirometry Cardiac CT
Transoesophageal
Echo
Symptoms? Consider BNP
Cautious stress testing
High BNP? Symptoms?
Follow closely in
COPC until symptoms are present
Cardiac surgical Conference
Cardiologists Cardiac Surgeons
Cardiac Anaesthetists CVICU Specialist
Cardiothoracic
Coordinator
Discussion regarding
sutureless AVR among the surgeons
Risk assessment for
sAVR2
Surgical
Waiting List CPAC Criteria to
prioritise
Standard surgical AVR
Sutureless AVR
4
BAV
Heart Team Interventional cardiologists
Cardiac Surgeon Imaging Cardiologist
Cardiac anaesthetist/Intensivist Coordinator
Geriatrician Input
Suitable for TAVI?3
Approach discussed
TAVI Waiting List Priority given
TAVI Transfemoral
Transapical
Transaortic
1. See Frailty Score attached;
however, the assessment is still
under development
2. See criteria for surgical risk
assessment
3. See TAVI eligibility criteria
4. See Sutureless AVR criteria
Figure 1: Model of care in severe AS
Briefing Paper for Meeting on: 28th February 2014
Pathway of Care for aortic stenosis (AS)
NHC MTANZ 2014
Index admission costing data
9% 2%
57%
1%
2%
17%
8% 4%
TAVI COST BREAKDOWN
medical labour
Allied labour
implant cost
Blood
labs
ICU
theatre
ward
17%
1%
14%
4%
4% 29%
21%
10%
SAVR COST BREAKDOWN medical
labour
Alliedlabour
implantcost
Blood
labs
ICU
theatre
ward
Cost Comparison of Trans catheter Aortic Valve Implantation (TAVI) with Surgery for patients with
severe symptomatic aortic stenosis.
Bhattacharyya S1, Roskruge M1, Haynes S2, Ramanathan T2, Webster M2, Ruygrok P2
1National Health Committee, 2Auckland City Hospital
NHC MTANZ 2014
EGFR-TKI questions …
• New Zealand mutation rate
• BOD and model of care for lung cancer
• Target population for TKIs
• Model of care for tumor biopsy
• Model of care for specimen management
• Cost inputs, testing platforms, TKIs etc.
• Comparison existing vs. new model of care
NHC MTANZ 2014
Challenges
New Zealand values the health and wellbeing
of our citizens above all else
Health is a complex, adaptive, resource
expensive business
To ensure value for money, affordability,
sustainability and strong growth in GDP we
must work together!
NHC MTANZ 2014
NHC MTANZ 2014