The Evolution of HTA in Emerging Markets Health-Care ... - TREE

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OHE Consulting Report for PhRMA 5 January 2011 party payers will argue it is in the interests of all members of society as enrolees or taxpayers that funds are used efficiently. Ultimately, all services will be seen as candidates for HTA. Key aspects of system architecture such as payment mechanisms and incentives will also come under scrutiny and so candidates for “macro” HTA to assess their cost-‐effectiveness in delivering health gain and broader societal objectives for the health care system. Lessons for the Three Markets in the Context of the Model We drew on the detailed case studies of Brazil, China and Taiwan, set out in the Appendices and summarised in Section 7, using the conceptual framework of our model, to: Identify common themes, issues and lessons across these health care systems with respect to their evolving use of HTA; Make specific comments in relation to each of the three health care systems. Lesson 1: Incomes are growing in emerging markets, but resulting increases in funding for health care are likely to be out-‐paced by rising demands and expectations. In such situations, HTA may have a role in assisting the health care system to reconcile rapidly expanding demand with more slowly expanding resources. HTA can provide a potential means of handling this in a more explicit and transparent way, and in promoting public debate about priorities. However, addressing ‘rationing’ in this way requires a willingness to engage in active debate about ways of addressing demand and supply. Such a debate will inevitably refer to the appropriate balance between national procurement and individual clinician decision making. Lesson 2: HTA of individual technologies is not a substitute for the reform of health care systems. Where health care systems create obviously bad incentives, this type of micro HTA is unlikely to compensate for these failings. HTA should not be approached out of context. HTA should be tied, in a case-‐by-‐case way, to what else is going on in the health care system. Lesson 3: ‘One size fits all’ HTA processes and methods are unlikely to be appropriate for emerging markets. There needs to be clarity over the purpose of HTA – and the methods and processes which are adopted need to be fit for purpose. HTA is not an objective ‘tool kit’ that is transferable to any setting. “Value” of new drugs varies, and is subjective and based on local preferences and other values. Real value depends in a “second-‐best” world on the match between costs and the value of all other inputs (hospitals, physician, nurses, equipment, etc.). 12
OHE Consulting Report for PhRMA 5 January 2011 Lesson 4: HTA and pricing regulations work hand in hand: the approach to HTA should be appropriate to, and work sensibly in combination with, the particular approach to pricing technologies. For example, HTA based on reimbursement levels ignores what providers actually have to pay for new drugs. This would tend to under-‐estimate real-‐world cost-‐effectiveness Lesson 5: There is no single prescription for HTA methods and processes which will be welfare-increasing in all contexts. Further, trade-‐offs between competing objectives are likely if not inevitable; and health care systems may differ in the relative value placed on them, for example, the achievement of equity goals; technical efficiency; cost containment; and patient choice. Every health care system is on a slightly different trajectory: as it develops, and as spending increases, the way that HTA evolves will be a reaction to the possibilities and pressures that new technologies present. The key message is that the relevance and positioning of any role for HTA in a health care system depends on the development stage and structure of that health care system. Options for the development of HTA in the three markets In positioning HTA, it is important to understand that its value depends on the existing architecture of the health care system. This will in turn reflect the type of HTA that is appropriate. We have categorised HTA into three types, one “macro” and two “micro”: “macro-‐level” HTA which is about the efficiency of the “technologies” or architecture of the health care system, e.g. incentive systems or configurations of facilities. Issues around the effectiveness of, or reform options for, system level technologies arise at all stages of health system development either for government as a regulator or, more typically, for government as a direct owner of, and/or a purchaser of, health care services; micro-‐level” HTA aimed at appraisal of individual technologies, or groups of related technologies. Initially, some sort of market entry or licensing requirements are introduced for certain technologies (notably drugs and some devices), but at some point a greater understanding of value may be sought, either in the sense of relative or comparative effectiveness, or of incremental cost-‐effectiveness. In theory, again, these assessments could be generated and adopted by clinicians in self-‐pay markets, but it hard to see how this type of HTA would be funded in such a situation given its public good characteristics and the asymmetry of information between doctors and patients. More typically, it is generated by public bodies and used by public and private sector payers to either (i) support doctors and patients making treatment choices or (ii) to define the boundaries of the “benefit package.” Use to inform listing or reimbursement can be as part of a “passive” fee-‐for-‐service system or more “active” purchasing. “micro-‐level” HTA aimed at developing clinical practice guidelines or the way in which individual technologies are combined within a delivery system to manage patients efficiently. Designing clinical practice guidelines becomes an issue in systems that are seeking to actively manage chronic disease. In theory, these could also be generated and adopted by clinicians in self-‐pay 13
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