1. NATIONAL HEALTH COMMITTEE PETER GUTHRIE AND ANNE KOLBE NATIONAL HEALTH COMMITTEE 2015

2. DISCLOSURE INFORMATION Peter Guthrie BA LLB General Manager National Health Committee Anne Kolbe ONZM, MBBS (Hons), FRACS, FRCSEng (Hon), FCSHK (Hon), FRCSEd (Hon), MAICD Chair National Health Committee Paediatric Surgeon Adjunct Associate Professor, University of Auckland Member, HealthPACT Member, Hospital Advisory Committee, Auckland District Health Board Member, Risk and Audit Committee, Whanganui District Health Board Co-chair, Policy Working Group International Global Leaders in Genomics Previous: Director, Pharmaceutical Management Agency Previous: President Royal Australasian College of Surgeons Chair, Review South Island Neurosurgery, 2010 NATIONAL HEALTH COMMITTEE 2015

3. Mirror, Mirror on the Wall, The Commonwealth Fund, June 2014

4. Source: OECD Health Data, 2012 NATIONAL HEALTH COMMITTEE 2015

5. GROWTH IN CORE CROWN HEALTH SPENDING HAS OUTSTRIPPED NATIONAL INCOME … Core Crown health expenditure per capita and GDP per capita indexed real growth Nicholas Mays, London School of Hygiene and Tropical Medicine Affording Our Future, Wellington, December 2012 NATIONAL HEALTH COMMITTEE 2015

6. Nicholas Mays, London School of Hygiene and Tropical Medicine Affording Our Future, Wellington, December 2012 NATIONAL HEALTH COMMITTEE 2015

7. NATIONAL HEALTH COMMITTEE Statutory Advisory Committee responsible for providing the New Zealand Minister of Health with independent, evidence based recommendations on:  Which technologies should be publicly funded  To what level and where technology should be provided  How new technology should be introduced and old technology removed So as to provide New Zealanders with the most effective health services within the public health budget NATIONAL HEALTH COMMITTEE 2015

8. WHAT ARE WE TRYING TO ACHIEVE?  High quality health, wellbeing and independence outcomes for individual patients and populations  Evidence based value for money  Sector sustainability  Enhanced health contribution to GDP growth The NHC will be remembered for how it contributes to the first three goals – “bending the cost curve” through technology adoption and management Sustainability: Continuing to provide the range and types of services (outcomes) currently available, or better, without incurring excessive levels of taxes and / or debt VfM = measurable health outcomes / $ value resources invested NATIONAL HEALTH COMMITTEE 2015

9. NHC PROGRAMME BUDGET 2013 NHC ANALYSIS OF 2010–2013 NMDS Source: NHC Strategic Business Plan 2014/15-17/18 NATIONAL HEALTH COMMITTEE 2015

10. TECHNOLOGY MANAGEMENT STREAMS AND TOOLS Proactive Work streams Reactive Referrals Pull model Streams Sector Programme Budget Tiered business cases Notional Budget Sector annual referral round Innovation fund, HRC &CI Tools NATIONAL HEALTH COMMITTEE 2015

11. NHC APPROACH: MODEL OF CARE Disease Groups Population Groups Models of Care (Systems Design) Technologies NATIONAL HEALTH COMMITTEE 2015 Most effective mix of technologies and clinical services

12. MODELS OF CARE Feasibility Societal & ethical considerations Clinical safety & effectiveness Economic General population At risk of condition Has the condition ( few co- morbidities) Advanced condition, multiple comorbiditie s End-stage condition

13. APPROACH: BOTH LEVERAGING WHAT WE HAVE AND NEW TECHNOLOGIES FOR HIGH BENEFIT/HIGH VALUE Old + New Combining what we have in new creative ways Adding disruptive new technologies Adoption Conditions NATIONAL HEALTH COMMITTEE 2015

14. OUR PARTNERS Extending the proactive work programme to work with industry Eight HIP grants focussed on COPD, IHD and EGFR Pull into the sector disruptive technologies Capture the spill over effects from technology diffusion NATIONAL HEALTH COMMITTEE 2015

15. WORK STREAM TIMING Musculoskeletal / Eye Hepatobiliary / Kidney and Urinary (TBC) Respiratory -> Chronic Obstructive Pulmonary Disease Cardiovascular ->Ischaemic Heart Disease Neoplasm / Endocrine Genomics ‘Omics’ Digestive / Mental Health (TBC) 201320142015201620172018 Frail elderly Age-related macular degeneration, low back pain & IORT Diagnostics -> Haematuria Aortic Abdominal Aneurysm 2014/15 Reactive Referrals DiseasePopulationModels of Care (System) Cardiac Cluster Have we got it right? Are there specific developments in these areas? Key Intended proactive workstream 2014/15 reactive referral 2012/13 reactive referral Proactive workstream 2013/14 reactive referral

16. Leading cause of vision loss and blindness in adults over the age of 50 At least 30,000 New Zealanders are affected Prevalence expected to x2 in next 20 years Costs per annum (N = 13,000) $20.5 million $41 million $205 million NATIONAL HEALTH COMMITTEE 2015 AGE RELATED MACULAR DEGENERATION

17. AMD MODEL OF CARE Early Identification Risk Stratification Anti-VEGF Low Vision Rehabilitation N = 14,000 - 42,000 Costs $12 - $21.5M N = 115,000 - 165,000 Costs = $4.3 - $6.2M N = 6000 Costs = $3.7M NATIONAL HEALTH COMMITTEE 2015

18. Public Education & Awareness Low vision rehabilitation Prevention Activity Ophthalmology Prioritisation Tool Intravitreal Anti-VEGF Treatment Primary and community care Secondary care Palliative care Ministry National Health Board Business Unit Low Vision Services Service Development Ministry National Health Board Business Unit Low Vision Services Service Development Population Screening Measurable health, wellness and independence gains for patients and populations Workforce Information Capital investment Purchase and procurement goods and services Costs and funding bundles PHARMAC Aflibercept Assessment Trained Nursing staff delivering intravitreal treatments AMD genomic diagnostic risk stratification HWNZ Optometry & Ophthalmology scope of practice NZBF AMD prevalence Study Funding Streams incentives and disincentives Equipment in the community

19. AMD GENOMIC DIAGNOSTIC - RISK STRATIFICATION NATIONAL HEALTH COMMITTEE 2015

20. WHERE TO FROM HERE? Direct-to-Consumer Personal Genome Testing for Age- Related Macular Degeneration ‘CONCLUSIONS. Direct-to-consumer personal genome tests are not suitable for clinical application as yet. More comprehensive genetic testing and inclusion of environmental risk factors may improve risk prediction of AMD’ Invest Ophthalmol Vis Sci. 2014;55:6167–6174. DOI:10.1167/iovs.14-15142 NATIONAL HEALTH COMMITTEE 2015 23andMe, deCODEme, Easy DNA, Genetic Testing Laboratories In that study serum free thyroxine levels were positively associated with development of AMD

21. The Economic and Functional Impacts of Genetic and Genomic Clinical Laboratory Testing in the United States. American Clinical Laboratory Association 2012 116,000 U.S. jobs $6 billion in personal income for U.S. workers $9.2 billion in value-added4 activity $16.5 billion in national economic output NATIONAL HEALTH COMMITTEE 2015

22. DISRUPTIVE COMPOSITE BIOMARKER HAEMATURIA MODEL OF CARE Investment Cxbladder NATIONAL HEALTH COMMITTEE 2015

23. PULL MODEL AND EMBED MODEL Extending the proactive work programme to work with industry Eight HIP grants focussed on COPD, IHD and EGFR Pull into the sector disruptive technologies Capture the spill over effects from technology diffusion NATIONAL HEALTH COMMITTEE 2015

24. INNOVATION FUND THE PAYERS’ PROCUREMENT LIFECYCLE NHC’s forecasts Priority setting Planning Care Models Business problem 5-15 years Needs Identification Sounding board Solutions considered Engage research community 3-10 years Ideation & Research Develop and apply “disruptive” technologies CI grants 2-5 years Commercial Vehicles Generate evidence Watching brief 2-5 years Clinical Trials NHC Innovation Funding 1-3 years DHB Case for Change (Field Trials) Sector adoption Product development for global market 0-ongoing Market Penetration Ensuring: The pipeline of emerging technologies aligns with New Zealand payers’ priorities The NHC’s advice is accepted and adopted High impact National Health Committee Callaghan Innovation Product Procurement 0-3 years Product utilised Ongoing Strategic Procurement Horizonscanning Strategicrelationshipmanagement 3-10 years NATIONAL HEALTH COMMITTEE 2015

25. PULL AND EMBED NZ GOVERNMENT INFRASTRUCTURE FUTURE DEMAND SIGNALS (NHC) GOVT. RESEARCH FUNDING PRIORITIE S (HRC) PAYER CURRENT & FUTURE SPEND (DHBs) BUSINESS DEVELOPMENT AND R&D GRANTS (CALLAGHAN) REGULATORY AND CASE FOR CHANGE (NHC) NATIONAL HEALTH COMMITTEE 2015

26. NHC Terms of Reference Section 6.2 (b) an understanding, and the skills and experience to ensure, that better national stewardship of the investment in health technology and services will lead to enhanced service delivery for all New Zealanders within the resources available Responsibilities of doctors in management and governance www.mcnz.org.nz 2011 NATIONAL HEALTH COMMITTEE 2015 WISE STEWARDSHIP OF HEALTH CARE RESOURCES

27. The Institute of Medicine Best Care at Lower Cost: The Path to Continuously Learning Health Care in America, 2012 Approximately 30% of U.S. healthcare is duplicative or unnecessary Inappropriate or over-utilized medical tests account for $250 to $300 billion in U.S. medical expenses each year Inappropriate testing not only compromises the quality of care but, in some cases, may pose risk or harm to patients by leading to more testing and unnecessary procedures or medication NATIONAL HEALTH COMMITTEE 2015

28. CHOOSING WISELY American Board of Internal Medicine Foundation boldly invited professional societies to own their role as “stewards of finite health care resources” “Five Things Physicians and Patients Should Question” NATIONAL HEALTH COMMITTEE 2015

29. Do not perform population-based screening for 25-OH- Vitamin D deficiency. Do not perform low-risk human papillomavirus (HPV) testing. Avoid routine preoperative testing for low-risk surgeries without a clinical indication. Only order methylated septin (SEPT9) on patients for whom conventional diagnostics are not possible. Do not use bleeding time tests to guide patient care. NATIONAL HEALTH COMMITTEE 2015 CHOOSING WISELY

30. Choosing Wisely – The Politics and Economics of Labeling Low-Value Services. N Engl J Med. 2014 February 13, 370 (7): 589-592. doi.1056/NEJMp1314965.

32. LABORATORY SERVICES NATIONAL HEALTH COMMITTEE 2015

33. AN OVERVIEW OF LABORATORY SERVICES IN NEW ZEALAND  Encouraged by the sector to take a more strategic approach particularly relating to:  workforce planning and career pathways  long term contracting, including public / private partnerships  national processes to assess new tests and research into new tests and unnecessary testing  Working with the Ministry of Health’s National Laboratory Roundtable to develop a more robust Overview document to inform strategic medium to long term national planning  Working with the medical profession through the Council of Medical Colleges engaging in Choosing Wisely NATIONAL HEALTH COMMITTEE 2015

34. FOUR YEAR STRATEGIC PLAN NATIONAL HEALTH COMMITTEE 2015

35. MULTI CRITERIA DECISION MAKING METHODOLOGIES MEGA ANALYSIS NATIONAL HEALTH COMMITTEE 2015 Specific Weighted Outcomes  Clinical safety and effectiveness  Health and independence gain  Materiality  Feasibility of adoption  Policy congruence  Equity  Acceptability  Cost effectiveness  Affordability  Risk Evidence: level of certainty / assumptions / risk High Moderate Low Very low Dynamic! Systems! Medium to long term horizon! NATIONAL HEALTH COMMITTEE 2015

36. TOOLS - TIERED BUSINESS CASES Source: NHC Strategic Business Plan 2015/16–2018/19 NATIONAL HEALTH COMMITTEE 2015

37. NATIONAL HEALTH COMMITTEE AND CALLAGHAN INNOVATION WORKING TOGETHER NHC’s forecasts Priority setting Planning Care Models Business problem 5-15 years Needs Identification Sounding board Solutions considered Engage research community 3-10 years Ideation & Research Develop and apply “disruptive” technologies CI grants 2-5 years Commercial Vehicles Generate evidence Watching brief 2-5 years Clinical Trials NHC Innovation Funding 1-3 years DHB Case for Change (Field Trials) Sector adoption Product development for global market 0-ongoing Market Penetration Making the commercialisation of medical technologies and services easier - and at the same time improving health system outcomes National Health Committee Callaghan Innovation How do we strengthen this process so that it contributes more effectively to the health system’s continuing capacity to deliver the health outcomes New Zealanders expect - despite emerging pressures and tight fiscal realities - through the adoption of right-headed innovations? NATIONAL HEALTH COMMITTEE 2015