1. “Disinvestment: What Does it Mean in the Canadian Context?” Public Payor Perspective CADTH Symposium April 2016 Chad Mitchell, MSc. Pharm A/Executive Director, Pharmaceuticals and Supplementary Health Benefits Alberta Health

2. CURRENT STATE “Creating Headroom” Projected deficit in Alberta High-cost, precision drugs Anticipated increase in drug spend High-yield generic drug savings

3. CREATING HEADROOM “I’m disinvesting and I didn’t know it!” OR “Disinvestment and it’s 43 related terms” 1 Figure from: Parkinson, Serment, Clement et al., Disinvestment and Value-Based Purchasing Strategies for Pharmaceuticals: An International Review. PharmacoEconomics. Published Online 06JUN2015 1: Adapted from Gnijidic & Elshaug. De-adoption and its 43 related terms: harmonizing low-value care terminology. BMC Medicine (2015) 13:273 Brand PLA / Generics Savings Appropriate Prescribing Treatment Restriction Alberta’s ROBS Policy

4. CREATING HEADROOM “Breaking up is hard to do” OR “Why disinvestment is harder than investment” 1 PAYER PHARMA TECHNOLOGY LAB / Device PATIENT JURISDICTIONAL Media / Public PROVIDER RETAIL HEALTH -------- ------ -------- --------- -------- ------ SUPPORT TOOLS/ GUIDELINES EVIDENCE REVIEW POLICY CYCLE

5. THE ANSWER IS 17 “Now what is the question?” It is frequently stated that it takes an average of 17 years for research evidence to reach clinical practice. 1 With countries trialling new strategies, evaluation is critical, as is knowledge sharing to support continual effective reform. 3 The challenges associated with disinvestment bring additional challenges for the standards applied to investment decisions. 2 Figure 1 Morris et al., The answer is 17 years, what is the question: understanding time lags in translational research. J R Soc Med 2011: 104: 510–520. 2 Haas et al., Breaking up is hard to do: why disinvestment in medical technology is harder than investment.. Australian Health Review, 2012, 36, 148–152 3 Parkinson, Serment, Clement et al., Disinvestment and Value-Based Purchasing Strategies for Pharmaceuticals: An International Review. PharmacoEconomics. Published Online 06JUN2015

6. REINVESTMENT “What do you think are the next steps?” Those standing to loose the technology have a stronger incentive to lobby for the continuation of the status quo, than gainers do for effecting the change. 1 Role of Government could be to support at the: –Stakeholder Level: Resistance/Time to changing prescribing behaviors Articulating Opportunity Costs –Policy Level: 1) Adapted from: Haas et al., Breaking up is hard to do: why disinvestment in medical technology is harder than investment.. Australian Health Review, 2012, 36, 148–152 2) Adapted from: Parkinson, Serment, Clement et al., Disinvestment and Value-Based Purchasing Strategies for Pharmaceuticals: An International Review. PharmacoEconomics. Published Online 06JUN2015 Increasing focus towards ‘active disinvestment’ with metrics for dis(re)investments identified a-priori. 2