Affordability
of Healthcare:
Role of HTA
Mairin Ryan
Director of Health
Technology
Assessment
Diminishing health budgets:
Space for innovation?
• Demographics
•
•
•
•
Medical inflation
Staff costs and impact of Moratorium
Medical card eligibility review
Commitment to fund cost-effective drugs
Why do we need HTA?
• Limited resources
• Unlimited ‘wants’ and new technologies
• Choosing between which ‘wants’ we can ‘afford’ given
our finite resources and budget
The best interests
of the individual
Fair & equitable
allocation
of resources
for society
Health Technology Assessment
Science
Patient
wishes
Industry
claims
Decision
making
“HTA is a decision support tool”
Multidisciplinary process, summarises information about
– Safety
– Clinical and cost-effectiveness
– Budget impact
– Organisational impact / resource implications
– Social and ethical issues
related to use of a health technology in a systematic,
transparent, unbiased and robust manner
How do we measure value?
The incremental cost-effectiveness ratio is usually
represented graphically as a line passing through the
origin on the cost effectiveness plane
Cost (€)
Q4
Q1
Accept
(probably)
€10,000/QALY
Effect
(QALY)
Q3
Q2
Cost-effectiveness plane
The incremental cost-effectiveness ratio is usually
represented graphically as a line passing through the
origin on the cost effectiveness plane
Cost (€)
Q4
Q1
Reject
(probably)
€60,000/QALY
Effect
(QALY)
Q3
Q2
Budget impact
Budget impact matters – even when a technology is
deemed cost effective?
How can we use HTA to address
affordability challenges
• Identify cost-effective interventions
•
•
•
•
Estimate Budget Impact
Cost-consequence analysis
Better use of resources
Disinvestment
Cost-effectiveness
• Drugs: NCPE
• National policy decisions: cancer
screening, vaccination, public access
defibrillation
• Medical devices and diagnostics
• Care pathways and clinical guidelines
National QA Criteria for Clinical Guidelines
Relevant criteria
HIQA 2011
10. Systematic methods have been used to search for evidence on
effectiveness and cost-effectiveness to ensure that the clinical
guideline is based on best available evidence. The full search strategy
should be clearly outlined
14. The health benefits, side effects, risks, cost-effectiveness,
resource implications and health service delivery issues have been
considered in formulating the recommendations
23. The potential budget impact and resource implications
(equipment, staff, training etc.) of applying the recommendations
have been considered
How can we use HTA to address
affordability challenges
• Identify cost-effective interventions
•
•
•
•
Estimate Budget Impact
Cost-consequence analysis
Better use of resources
Disinvestment
Deep Brain Stimulation
• Surgical treatment for
controlling the symptoms of
Parkinson’s Disease, Dystonia
and Essential Tremor
• Not curative, adjustable and
reversible
• At present patients are referred to DBS centres abroad
(primarily UK), funded through the E112 Treatment
Abroad Scheme
• This HTA evaluates the provision of a national DBS service
for PD, ET and dystonia compared with continuing to
provide this service via the TAS
Results of economic analysis
Cost per patient over 10 years
(€)
5 year budget impact
(million €)
65726
6.13
44664
TAS funded model
4.29
National DBS programme
A national DBS programme would cost
€21,000 more per patient over 10 years
TAS funded model
National DBS programme
A national DBS programme would cost
€1.84M more over 5 years
Impact of private health insurance
•
For patients with PHI, the insurer pays a greater
proportion of the cost of DBS treatment if it is provided
abroad than if the procedure is undertaken in a publiclyfunded hospital in Ireland.
•
Approximately 32% of Irish DBS patients have PHI
TAS funded DBS model
National DBS Programme
PHI
All in-patient procedures in the
UK, including full cost of
surgery and DBS device
Per diem rate for every day spent in
hospital
HSE
Out-patient procedures,
consultant appointments in
Ireland
Surgery, device, imaging,
additional costs of inpatient
procedures, outpatient procedures
Impact of private health insurance
Cost per patient over 10 years (€)
TAS funded model
National DBS programme
65909
65726
61780
46873
44789
44664
Current Situation
Irish service costs:
€21k more
Absence of PHI
€4k more
Equivalent PHI reimbursement
€2k more
Public Access Defibrillation
•
•
Approximately 9K AEDs currently in circulation, half of which are in designated
places identified in the Bill
Evidence suggests that static AED provision is more effective than uniformed first
responder programmes
Number of
additional
AEDs
required
Increase in
annual
survival to
discharge
[n(%)]
Incremental
costeffectiveness
ratio (ICER)
(€/QALY)
PAD15%
1,900
2 (1.7)
PAD20%
3,100
PAD25%
Public access
defibrillation
(PAD)
programme
Total incremental budget impact
over five years (€)
Health
service
Public
sector
(excluding
health)
Private
sector
96,000
€1.0M
€1.0M
€3.3M
2 (1.9)
Dominated
€1.1M
€2.9M
€4.6M
6,800
4 (4.0)
151,000
€1.5M
€2.9M
€14.4M
PAD45%
15,300
7 (6.9)
214,000
€2.0M
€17.0M
€24.4M
PAD55%
19,600
8 (7.7)
374,000
€2.2M
€14.9M
€37.1M
Legislation
38,400
10 (9.3)
928,000
€2.4M
€17.6M
€85.0M
How can we use HTA to address
affordability challenges
• Identify cost-effective interventions
•
•
•
•
Estimate Budget Impact
Cost-consequence analysis
Better use of resources
Disinvestment
Health Information & Quality
Authority
Technology
Cost
Consequence
Colorectal cancer €12-15 million /yr 270 lives saved/yr
screening
by yr 10
Prion filtration of €11 million/yr
blood supply
Public access
defibrillation
2 lives saved/10
yrs
€105 million/5 yrs 10 lives saved / yr
How can we use HTA to address
affordability challenges
• Identify cost-effective interventions
•
•
•
•
Estimate Budget Impact
Cost-consequence analysis
Better use of resources
Disinvestment
Incremental cost effectiveness ratio
(ICER)
Incremental cost effectiveness
ratio (ICER)
AED utilisation
100000
80000
60000
€45,000/QALY
40000
20000
~20% increase in AED
utilisation within 200m of all
OHCAs (public & residential)
0
100000
90000
80000
70000
60000
50000
40000
30000
20000
10000
0
1 1.05 1.1 1.15 1.2 1.25 1.3 1.35 1.4 1.45 1.5
Relative increase in AED utilisation within 200m of an OHCA
€45,000/QALY
1 1.08 1.16 1.24 1.32 1.4 1.48 1.56 1.64 1.72 1.8
Relative increase in AED utilisation wihtin 200m of a public OHCA
~40% increase in AED
utilisation within 200m of
public OHCAs (assuming no
change for residential
OHCAs)
A series of health technology assessments (HTAs) of
clinical referral or treatment thresholds for
scheduled surgical procedures
A series of health technology assessments
(HTAs) of clinical referral
or treatment thresholds for
scheduled surgical procedures
2013
Safer Better Care
•
•
•
•
•
•
•
Tonsillectomy
Grommet insertion
Varicose veins
Cataract
Hand surgery
Back procedures
Hip, knee and shoulder
procedures
• Gastro procedures
Informed Decision Making……..
Value-based Healthcare:
achieving the best outcomes
at the lowest cost
Porter M, Lee T, Harvard Business Review 2013
Issues for Conduct of HTA
• Skill sets:
– Clinical evaluation, systematic literature review,
biostatistics, mathematical programming, health
economics, health services research, ethical and
legal expertise, communication skills (written and
oral)
• Quality Assurance
• Data quality and availability
• National HTA Guidelines
• Efficient use of HTA
• International Collaboration
Issues for Conduct of HTA
• Skill sets:
– Clinical evaluation, systematic literature review,
biostatistics, mathematical programming, health
economics, health services research, ethical and
legal expertise, communication skills (written and
oral)
• Quality Assurance
• Data quality and availability
• National HTA Guidelines
• Efficient use of HTA
• International Collaboration
HTA Guidelines
Guidelines for the
Budget Impact
Analysis of Health
Technologies in
Ireland
2010
Guidelines
for the
the
Guidelines for
Evaluating
Budget Impact
Clinical Effectiveness
of Health
Analysis
of Health
Technologies
in Ireland
Technologies in
Ireland
2011
2010
Safer Better Care
www.hiqa.ie
Issues for Conduct of HTA
• Skill sets:
– Clinical evaluation, systematic literature review,
biostatistics, mathematical programming, health
economics, health services research, ethical and
legal expertise, communication skills (written and
oral)
• Quality Assurance
• Data quality and availability
• National HTA Guidelines
• Efficient use of HTA
• International Collaboration
1. Data Gathering
HTA Business
Intelligence
Horizon Scanning
Prioritisation Advisory
Group (PAG) meeting
Screening
PAG members
HTA requests
Internal HTA
Prioritisation Meeting
List of selected HTAs
circulated to PAG
for feedback
Final HTA workplan
submitted for Board approval
HTA Prioritisation Criteria
Clinical
impact
Policy
environment
Economic
impact
Information
availability
Link to
decision
making
Resource
availability
Issues for Conduct of HTA
• Skill sets:
– Clinical evaluation, Systematic literature review,
Biostatistics, Mathematical programming, Health
economics, Health services research, Ethical and
legal expertise, Communication skills (written and
oral)
• Quality Assurance
• Data quality and availability
• National HTA Guidelines
• Efficient use of HTA
• International Collaboration
International Collaboration
EUnetHTA
HTAi
European Network For Health
Technology Assessment
Health Technology
Assessment International
HIQA
INAHTA
International Network of
Agencies for Health
Technology Assessment
HTAN
Health Technology
Assessment Network
Developments 2014 onwards
• Implementation of Prioritisation Process
• Money Follows the Patient
• HTA Academic Research
• Institutional HTA: mini-HTA
• Universal Health Insurance
– Universal Health Access & basket of care
Thank You
mryan@hiqa.ie