1. Health Technology Assessment and evidence-informed decision making
Derek Cutler, MSc
NICE International

2. Health systems everywhere are under pressure…
Burden of chronic disease and ageing populations
Users’
expectations and the promise of universal coverage
Finite budgets and financial pressures
Policy and practice
Growth in technologies – expanding marketplace

3. 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

4. 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…
Accumulating debt - unsustainable
(Arbitrary) price cuts - Illegitimate in eyes of industry
Divergence between coverage (in principle) and access – poor result for public and untimately for policy makers
Cost-shifting to service users and their families – poor for public
Price negotiations – need to be well informed. Not always possible due to reference pricing
Risk sharing and Value-Based Pricing – difficult to implement; high burden on health system

5. 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)
Not just drugs. Also services, quality – systems approach

6. 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
Final point: indicators not always financial incentives alone.

7. 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

8. 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
Policy-makers – payers – want most impact for $$
Medical products developers – industry – Market access
Healthcare professionals – Concern with individual patient care
Academic community – researchers – publication impact
General public: taxpayers; insured population – Individual care; value for tax money
Patients and their families – Individual care

9. Dimensions of HTA Comparative clinical effectiveness
Comparative cost-effectiveness
Service delivery organisation aspects
Legal framework
Ethical, social implications – equity, fairness and other societal norms

10. 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

11. 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)
Few international guideline developers explicitly consider cost-effectiveness, though some take resources into account in a less-defined way. For NICE guidance, cost-effectiveness needs to be considered for all intervention questions. Also consider costs and budget impact when designing P4P (QOF) indicators

12. Cost-effectiveness and…
Extent of uncertainty
ADVISORY GROUP DECISIONS
Legal and policy constraints
Non-utilitarian criteria: ethics, equity, rights
Practicalities of implementation
Need to take other factors into account:
uncertainty (this matters if the decision has big, irreversible costs of implementation)
we are not simple QALY maximisers – we also care about other criteria, such as equity
Advisory body need to consider practicalities of implementation that are not included in ICER estimate
there may be other constraints on what can be implemented

13. NICE Principles Key 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

14. Process

15. Process matters Open, consultative decision-making processes:
Confer legitimacy
Improve the quality and relevance of decisions
Protect against vested interests and bias
Legitimacy – inclusive nature makes even controversial decisions defensible, more likely to have an impact, makes deciosn makers more accountable to service users and tax payers
Quality & relevance – because they draw on a wide variety of opinions and information

16. 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)

17. 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

18. Building capacity 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

19. Building capacity: HTA and policy-making: a symbiotic relationship?
Academics in the field of HTA driving policy
Policy makers driving academic HTA research
Result: Increased
knowledge
capacity
impact
in both areas

20. Need, demand, and supply are different in every country:
Demand for HTA
Who (departments, institutions) will be using the outputs of HTA?
Need for HTA:
What policy decisions will be informed by HTA?
Supply of HTA:
Who (departments, institutions) will be conducting HTA and running the HTA process?

21. 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

22. 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