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

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OHE Consulting Report for PhRMA 5 January 2011 o The Urban Resident Basic Medical Insurance (URBMI) is a voluntary subsidized insurance scheme for urban residents not in formal employment including children and students. The Ministry of Human Resources and Social Security (MoHRSS) is responsible for the UEBMI and the URBMI. The Ministry of Health (MoH) is responsible for the NRCMS. The Provinces also play an important role. Major issues The need to move away from hospital-‐based services, building a strong primary care based health delivery system with infrastructure building (township health centres (THCs)/village clinics in rural areas; community health centres (CHCs) in urban areas) with the government paying the costs of THCs and CHCs and these centre becoming “gatekeepers.” However, the costs of investing in this additional infrastructure will be high, especially as such reconfigurations are unlikely to lead to hospital closures. The need to restructure hospital finances. Many fee-‐for-‐service charges are now far below the market price levels. Hospitals are unable to cover costs without other revenue sources including providing services that are not included in the insurance package, so they do not have the right incentives to provide quality care. The need for new payment systems. One route currently being developed in some areas is improvements in payment mechanisms for hospitals with the development of “case based” payments, seeking to move away from fee-‐for-‐service towards DRG-‐type payments. These can be linked to clinical protocols derived from practice guidelines providing a “bottom up” way of paying for good clinical practice. The need to tackle chronic disease with better prevention and disease management. Reducing the incentives for over-‐prescribing. Given the ability to earn much-‐needed revenue from the margins allowed in pharmaceutical sales, hospitals therefore tend to provide incentives for doctors to over-‐prescribe. Drug over-‐prescription and inconsistent prescription has become a serious problem. Reform is under discussion to replace the 15% margin with a flat rate amount. The need to rationalise drug spending. The MoH has also introduced an Essential Drugs List with Provincial procurement to reduce hospital drug expenditures. A number of these issues are “macro HTA” ones around system architecture and incentives. In relation to the use of HTA, interest in “micro HTA” has been limited: The use of HTA is conceptually accepted in government’s documents (for example documents from the NRDC, MoHRSS and MoH) but nothing has been outlined as to the specifics of HTA other than the recent Memorandum of Understanding with NICE. This 54
OHE Consulting Report for PhRMA 5 January 2011 focuses on the development of clinical practice guidelines. NICE is looking to “help the MoH build capacity (institutional and technical) and to pilot the development/adaptation of evidence-‐informed clinical standards for best practice, taking account of efficiency and equity considerations” and with the aim of supporting the Chinese government with the NRCMS reform; The use of HTA in the context of pharmaceuticals is a newly developed discipline in China and approaches and methods for conducting HTA are not standardized. Pharmacoeconomic data have not been widely used in management of hospital formularies. However, an increasing number of (international) pharmaceutical companies in China have started using pharmacoeconomic evaluations as supportive evidence in marketing activity. 8.2.3 Taiwan Taiwan has a centralized National Health Insurance plan covering virtually all of the population. Providers are paid on a fee-‐for-‐service basis, but are subject to global budget caps that can be used to reduce fee levels across the board. Reimbursement levels for drugs are established based on the degree of “clinical improvement” and in relation to the median of 10 reference countries or to comparable drugs (if no or minimal improvements). HTA applied to drugs has been established only as a “pilot project” in Taiwan and is linked to the reference pricing system. However, providers are free to negotiate lower prices with drug manufacturers. The fact that the reimbursement level is higher than the acquisition cost means that providers are paid more by government than the amount they pay to purchase the drugs. This gives them an incentive to prescribe more. There is a misalignment of incentives which can give providers perverse incentives to provide inefficient but profitable services. Major issues Whether the new “second generation” of NHI under review in the legislative Yuan, which is expected to be completed in early December of 2010, more clearly defines the role of HTA? Whether reimbursement levels will eventually be directly tied to the HTA review and the estimated health gain, or will continue to be based on reference pricing? Whether the HTA process will become more open and transparent, involving more structured stakeholder involvement and a more well-‐defined timeline? The need to ensure the independence of the HTA process from undue government and political influence. The lack of HTA review of non-‐drug micro and macro-‐technologies. 55
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