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

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OHE Consulting Report for PhRMA 5 January 2011 8.2 Summary of findings on the three countries We set out our detailed findings on the health care systems and use of HTA in these countries in Appendices to this report. In this section, we describe some key attributes of the three systems in the context of our discussion of the evolution of health care systems and of HTA. 8.2.1 Brazil We have noted that health care financing evolves over time, moving from predominantly out-‐of-pocket funding to elements of insurance through to more-‐or-‐less universal coverage varying from country to country. Typically employer-‐based schemes for urban workers begin before schemes covering rural workers who are usually self-‐employed. In Brazil this was the case with the 1923 Eloi Chaves Law providing for employer-‐based insurance. The extent to which the various third party payer insurance schemes are combined over time varies from country to country. Some move to a single payer system, others keep multiple insurers and, in some cases, these insurers compete for enrolees. Brazil’s current system is the United Health System (SUS) introduced in 1988. It is a single payer universal coverage scheme with significant regional and local variation. There is, however, separate supplementary Private Insurance regulated by the National Agency for Supplementary Health (ANS). Regulated private insurance is the main provider of health care for many citizens (25% of the population) because of the limited financing of the SUS. The ANS fixes maximum premiums and procedures to be covered. These private plans need not cover oral drugs or home treatment. The element of any developing health care system that arguably evolves the most slowly is purchasing. Initially, insurance coverage typically accepts fee-‐for-‐service with the role of the third party payer being to passively pay the bills of the provider rather than actively decide what it is going to cover, who should provide it, and how they are to be paid. Over time, more sophisticated mechanisms for incentivising and rewarding providers tend to be used, notably capitation payments and ‘prospective’ or case-‐mix adjusted payments to hospitals. SUS uses diagnosis-‐related groups (DRGs). HMOs in Brazil are seeking to negotiate DRG-‐type packages. Brazil has three programmes for insurance coverage for pharmaceuticals. Covered drugs in all three programs are offered free to patients prescribed them, though, like in most countries, actual access and use vary geographically and by socioeconomic status. The National Commission for Technology Incorporation of the Ministry of Health (CITEC) reviews drugs on the Component of Specialised Pharmaceutical Assistance, which have a high budget impact. Issues around the use of HTA in Brazil Despite the creation of an HTA body (CITEC) focussing on “micro” HTA and hundreds of submissions, the delays in reviews and lack of transparency about the decision-‐making process have resulted in great uncertainty about its ultimate impact. The following issues and trends arise: HTA can be seen as a “black box” with little thought given to appropriate processes to ensure the involvement of stakeholders: clear parameters for decisions have not been made transparent. 52
OHE Consulting Report for PhRMA 5 January 2011 There appears to be unrealised potential for the use of HTA to support the use of evidence-based clinical practice guidelines to manage chronic diseases. HTA in Brazil could be a “product” without a customer if HTA decisions do not change the way in which patients are treated. Ambitions for the availability of health care (universality of health care by constitution) are not matched by public financing. It is not clear what role HTA plays in managing this discrepancy. Other “macro” elements of system architecture, such as incentives to prescribe and the importance of trading margins, are not being addressed by HTA or other review mechanisms. Other challenges for the Brazilian health care system: There is ambiguity about the role of private insurers. Limited budgets for public health care suggest that a heterogeneous public/private insurer market is likely to continue. Over-regulation of the private sector (i.e. fixing both premiums and minimum packages) has led to many exits. This has also led to a lack of clarity about the appropriate focus of HTA. Is HTA for the private sector also or just for the public sector? There is a lack of genuine “arm’s length” bodies and regulation – with direct political influence in specific operational decisions. This links to the fundamental need to distinguish between the different elements of government stewardship of the health care system. 8.2.2 China In China, major health care reform has been underway since 2003 with government-‐led attempts to re-‐establish universal coverage lost during the disruption of the early years of market reform in the economy. The Urban Employment Basic Medical Insurance (UEBMI) is a mandatory insurance scheme for formal sector workers in urban areas covering 200 million urban employed people. The other two insurance schemes are subsidised but voluntary. o The New Rural Cooperative Medical Scheme (NRCMS, also known as the NCMS) is a subsidized health insurance scheme for rural populations offering benefits covering primarily inpatient care and major outpatient expenses, with voluntary enrolment on a family basis. The intention is to move the benefit package away from insurance for expensive hospital care to one risk pool for inpatient and outpatient services, encouraging coverage for treatments for chronic conditions. 53
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