Centre for the Study of Assessment and Prioritisation in Health

1. Centre for the Study of Assessment and Prioritisation in Health History, Rationale, and Work Programme

2. History of Prioritisation in NZ Core Services Committee 1992First national body anywhere to try to define ‘the core’ Considerable conceptual and methodological work Criteria-based approach (e.g. effectiveness, equity) Priority criteria project - booking systemIn shadow of Oregon, which was getting bad press, CSC tried to distance itself from that effort

3. History, cont. • Core Services Committee became National Health Committee 1996Developed NZGG • Yielded prioritisation efforts to HFA 1997 • Review of HFA’s prioritisation process  1999 • Prioritising Health Services (background paper) Oct 2004; • Best Use of Available Resources: Dec 2004 • Health technology assessment May 2005This report led to creation of Service Planning and New HealthInitiative Assessment SPNIA

4. ‘Best Use’ Recommendations • The National Health Committee recommends that The Ministry of Health, in partnership with other health sector stakeholders, develop an integrated information and support strategy to promote understanding of prioritisation and further develop prioritisation capacity. Initiatives within this strategy could include: • Developing and maintaining a central library where examples of prioritisation analysis could be lodged. • Considering how best to provide specialised technical support for analysts and analysis. • Maintaining an email list for sharing information, advice, and best practice models amongst both those undertaking prioritisation analysis and other interested parties. • Running annual symposia on best practice in prioritisation. • Developing workshops for analysts to provide training in prioritisation tools and processes, and improving the availability of training in prioritisation amongst health professionals at both undergraduate level and in continuing professional development.

5. NHC says ‘no, not yet’ • Media Release 1 April 2004National Health Committee says “No, not yet” to prostate cancer screening The National Health Committee (NHC) is recommending against the introduction of prostate cancer screening in New Zealand.In a report to the Minister of Health today, the NHC says the most commonly available screening tests are not good enough. The NHC provides advice on the kinds of health and disability services that should be publicly funded and their relative priorities. The NHC reached its recommendation following a comprehensive review of the issue and says there is still no conclusive evidence to show that screening for prostate cancer makes any difference to how long a man will live. Furthermore, the committee says there is no conclusive evidence that early detection and treatment of prostate cancer will result in improved quality of life for men. “The prostate specific antigen, or PSA test, may detect the presence of prostate cancer in a man, albeit with a significant error rate,” says Dr Api Talemaitoga, a Christchurch general practitioner and a member of the National Health Committee. “What it won’t do is tell us accurately enough which cancers are slow-growing and not life-threatening and which are aggressive.” . . .

6. History, cont. • Pharmac (‘an international anomaly’) 1993 • Contractual approach to prioritisation • Cost-utility main input • Decision criteria (health needs of NZers, health needs of Maori, effect on budget, effectiveness, etc.) • Not clear how individual decisions linked to criteria

7. History, cont. • HFA 1997 – 2000 • Continued CUA and criteria-based approaches • Expanded work on horizontal prioritisation (across different services) • Substantial public and stakeholder consultation • Method received qualified blessing from NHCin 1999 • Disbanded in 2000 in wake of Labour victory

8. History, cont. • DHBs 2000 – present • Some good work in DHBs, ongoing – seeks to set programme priorities via rating systems • Not able to coordinate effortsNot much overall progress, in part due to lack of financial wiggle room for disinvestment • So, not enough traction to spread and be used nationally

9. History, cont. A national prioritisation renaissance?Began with Wellington Health Economist Group seminars:Gerald Minnee, Ruth Isaac. NZ Treasury. Health system sustainabilityin the long term: Why we need to act today. 22 May 2008Judy Kavanaugh. MOH. Prioritisation: why is it so hard? 21 August 2008Janet McDonald. Prioritisation: Change and Adaptation in Familieswith Young Carers. 11 September 2008David Hadorn and Martin Hefford. Saying ‘no’ in three countries:alternative methods of healthcare prioritisation. 16 October 2008(repeated at VUW and Treasury)

10. History, cont. • Discussions with key people (e.g., Margaret Earle, Peter Crampton, Matthew Brougham, Jackie Cumming, Wendy Edgar, David Moore, Geoff Fougere)  concerning best way to re-invigorate prioritisation in NZ • General agreement that some kind of impetus required, preferably from academic arena • Idea for new prioritisation centre based in DPH conceived in discussions between Peter Crampton and myself late Dec 2008

11. History, final • Steering group: Peter Crampton, Geoff Fougere, David Moore, Matthew Brougham, Jackie Cumming, Ed Mares, myself • Series of 3 discussion papers written in support of idea of new academic centre in UOW: • proposal for new centre; • proposed national prioritisation process, including role for new Centre; and • proposed work programme • Other important input from Helen Griffiths (MOH), George Laking (ADHB), Stephen Munn (ADHB), and Tony Blakely (DPH) • Dept Public Health agreed to host new Centre 10 July 2009

12. “Meeting the Challenge” • Ministerial Review Group (MRG) – Horn Report • Released 16 August 2009 • Has changed dynamic for health reform • Several recommendations support CAP’s mission • Quoted throughout rest of this seminar

13. Rationale Principal Objective: To create a fit-for-purpose centre to serve as an ‘academic anchor’ for governmental efforts to assess and prioritise of healthcare services in New Zealand, with the goal of fair and efficient allocation of these services

14. Rationale, cont. Primary Aims: • To assist in developing a systematic, efficient, and fair process for healthcare evaluation and systematic prioritisation • To facilitate and to help coordinate prioritisation efforts in NZ • To study healthcare assessment, including research design, health measurement, and statistical inference • To study the ethical aspects of prioritisation in order to develop recommendations for mitigating the ethical, cultural, and distributive pitfalls inherent in rationing health services • To provide a world-class academic environment for students and scholars, including research, teaching, and community service

15. Rationale, cont. From MRG report: [We recommend] revamping and strengthening the National Health Committee, so that it is better able to perform its original role of assessing the appropriateness and cost-effectiveness of new services, and progressively reassessing existing services. p 5 [my emphasis throughout][A] single national agency removed from both DHBs and the Ministry [is needed]. The best approach would be to strengthen the NHC . . . An essential component of this strengthening is to ensure the agency has the capability to conduct evidence-based assessment of the likely costs of new and existing procedures and interventions. 29 72

16. CAP’s Modus Operandi • To seek out and invite clinicians and researchers who are doing (or who would like to do) research in areas relevant to assessment and prioritisation to work with us • To build scholarly bridges and to develop networks to enable state-of-the-art research in key areas • To assist in brainstorming, preparing funding proposals and performance of projects • To serve as a forum and platform upon which to build a programme of research, teaching, and community service (e.g., sponsoring ‘town hall’ meetings to facilitate public discussion)

17. How Differs from Existing Centres? • Purpose-built for study of prioritisation • Healthcare assessment in this context • For example, rare for current HTAs to identify indications that are insufficiently effective (or cost-effective) to warrant public funding • Focus on methodological work • Formal philosophy connection for epistemology and ethical work • Aspiring to be central academic connection point for prioritisation, including for government

18. Governance Structure Director  David Hadorn Department of Public Health Co-directors • Tony Blakely Professor, DPH • Peter Crampton, Professor DPH, UOW and Dean, UOW • Jackie Cumming, Director, Health Services Research Centre, VUW • Ed Mares Chair, Dept of Philosophy, VUW)

19. Advisory board • Matthew Brougham, CEO, Pharmac • David Moore, Managing Director, LECG (former CEO Pharmac and head of Personal Health at HFA) • Deborah Roche, Deputy DG MOH • Norman Sharpe, Medical Director, National Health Foundation • Others TBI Main roles are to: (1) ensure CAP’s work remains relevant to real world and (2) Guard against ‘capture’ by medical community (a worry for some)

20. Evolution of name • Started with Centre for Healthcare Evaluation and Prioritisation • Changed to Centre for Assessment and Prioritisation (CAP) • Keep above as short name and acronym but expand full title to: • Centre for the Study of Assessment and Prioritisation in Health • Add ‘study of’ to emphasise academic, epistemological and methodological focus • Add ‘in health’ to clarify domain, which might not be obvious outside medical environment

21. Academic Work Programme • Divided into three main sections: policy, epistemology, and ethics Policy: • To analyse past efforts at reform, esp. the 1990s NZ reforms (paper and conference) • To (help) develop a prioritisation process that can work in NZ • To assess the applicability or generalisability of Pharmac’s model outside pharmaceuticals • To assess current clinical practices at the end of life (esp. in hospital) • To explore clinicians’ ability to help identify opportunities for disinvestment

22. Analyse past reforms • The health reforms of the 1990s, in particular, contains many lessons • Most advanced effort at complete purchaser/provider split and centralisation of planning and funding • Effectiveness and impact on equity? • Pharmac and CSC/NHC remain strong • A conference would be useful

23. Develop prioritisation process • The second CAP background paper described a possible process for setting health priorities in NZ • On this model, a National Healthcare Prioritisation Board (NHPB) would be created de novo • NHC would continue as now, rather than be ‘revamped’ • NHPB would develop list of services for both new investments and disinvestments based on advice from CAP and consultation • Parliament would have to accept or reject the entire list of investment and disinvestments, and could not make changes

24. Develop prioritisation process From MRG report: The MRG recommendations are for service prioritisation ‘at themargin’, rather than the more comprehensive approach first envisioned by the predecessor of the NHC and tried in some jurisdictions offshore [Oregon and ? NICE]. The MRG considered the experience in New Zealand and overseas with attempts to try and assess and prioritise all services and identify those ‘core’ services that should be publicly funded. We concluded that this was unlikely to succeed in the current environment. In any event, our more modest approach would probably be a useful prerequisite even if a more ambitious approach was to becontemplated in the future. 31 78

25. Assess Generalisability of Pharmac’s Business Model From MRG report: Outside pharmaceuticals, however, the current mechanisms for assessing the effectiveness and relative priority of health interventions are not as well developed. Strengthening these mechanisms will help improve the value and control the costs of improvements in healthtechnology. In particular, the MRG considers it both possible and desirable to develop a Pharmac-like process for assessing the cost-effectiveness of medical devices and prioritising them for public funding. 27 68

26. Study End-of-Life Care From MRG report [On prevention vs. cure] On the question of cost, it is not clear that living longer and generally healthier lives will necessarily reduce our demand on health and disability services over our lifetime. Half of all spending goes on the last year of life and the older we are the more likely we are to suffer from multiple conditions. In addition, many of us will live longer with long-term chronic conditions, like diabetes, that are expensive to treat and increase the risk of multiple conditions later in life. Information is needed on the impact of preventative and public health interventions on lifetime health and disability costs to guide future investment decisions in these areas. 50 114

27. End of Life Study • Initial focus is on why people die in hospital, rather than at home or hospice • Who is pushing for continued aggressive or curative treatment – patient, family, doctor? • What were the decision points? • Hypothesis: Communication of major importance • Planned in conjunction with palliative care team and Mary Potter Hospice researchers

28. Develop Disinvestment Strategies From MRG report: The NHC would also have to act within a defined budget for new interventions that was determined by the Minister [ . . .] taking into account likely savings from discontinuing existing interventions. 29 72As part of its prioritisation process, the NHC should also be asked toidentify and assess a number of existing interventions that, in theopinion of the NHC, the Minister or the Ministry appear to be lowpriority (e.g., have uncertain or relatively little health benefit netof the harm they cause). This should include existing health serviceswhose application may have been extended beyond the point wheresignificant net health benefits are demonstrable. 30 73

29. Role of GPs in Identifying Disinvestment Opportunities From MRG report: The Medical Council of New Zealand is clear that “ . .. doctors have a responsibility to the community at large to foster the proper use of resources and must balance their duty of care to each patient with they duty of care to the population.” The challenges we face require collective leadership . . . 19;53Achieving the “. . . optimum arrangement for the most effectivedelivery” of services will require . . . a transparent process for engagingclinicians in deciding the level at which services should be planned andfunded and how that should change over time. 33 81

30. Possible GP Reprioritisation Project • GPs have ‘birds-eye view’ of health system including long-term outcomes • Can assess value of specialist treatment better than specialists, incl long-term f/u • Have no vested interest regarding value of specific secondary tests and treatments • Represent a potentially significant source of information on relative value of services, per MRG report

31. Epistemology • Assist in ‘wiring the system for outcomes’, including patient-report outcome measures • Assess Oregon and NZ DHBs’ experience using transparent, criteria-based prioritisation • Compare efficiency of Google-based literature searches with standard approaches

32. Wiring system • Study feasibility of linking and expanding existing e-heath data to enable information about real-world effectiveness • Device registry a possible starting point • Address adequacy of control for possible confounders given non-randomised samples

33. Transparent Prioritisation From MRG report: The Minister would require the NHC to prioritise new interventions on the basis of their cost-effectiveness and identify the process the NHC must apply in making its decisions (such as any requirements forconsultation, consideration of ethical reviews, publication of the decision and its rationale, including the evidence on which the decision was made). 30 74 Transparency has its virtues and its downsides Ultimately however full transparency of process is probably necessary for national prioritisation decisions

34. Programme Scoring Components

35. Ranked Table of Initiatives

38. Compare Methods of Literature Review • Most contemporary lit reviews still done using very large and expensive searches of multiple databases • More efficient process required, given scope of prioritisation analyses required • Google and Google Scholar have not penetrated into health technology assessment • Comparison of efficiency and effectiveness long overdue • Compare results on about three substantial literature reviews using both methods

39. Ethics • Assess public acceptability of differential access to life-prolonging treatments, e.g., expensive new cancer drugs • Assess willingness of elderly to consider possible age limits on publicly funded high-tech and end-of-life care (perhaps in exchange for better comfort care and hospice service?) • Consider how to incorporate equity considerations in prioritisation • Study implications of incorporating anxiety and unrelated future health care costs into CUAs

40. Public Acceptability of Differential Access to Life-Prolonging Care • Would NZ public accept (or prefer) Canadian-style limits on care not available to all? • This would require those desiring non-available services to leave the country • When Canadians travel to the US to receive private care, a certain stigma is attached, a sense of social solidarity violated – how would NZers feel?

41. Age Limits on Public Funding? • Assess willingness of elderly to accept limits on publicly funded expensive care based on age • Possibly in exchange for enhanced comfort care and hospice? • Very sensitive topic • Must be seen as originating from elderly community • Separate from end-of-life project

42. Incorporating Equity into Prioritisation • Remains an important unresolved issue • NZ has made strides by adding points for Maori-relevant to health services and even health research grant funding • Also possible to adjust QALY or DALY based on which population experiencing gain/loss, amongst other approaches

43. Anxiety and Unrelated Future Costs in CUAs • Recall MRG quote on expenses incurred due to longer lives – huge implications • Anxiety and related emotional and social factors are a real and important outcome of many tests and treatments • These are rarely captured in CUAs • Pharmac found it made 100-fold difference in est. $/QALY depending on anxiety • Anxiety due to false-positive screens