bengt jönsson stockholm school of economics bengt.pdf · changes in the composition of total...
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THE CONTRIBUTION OF ECONOMICEVALUATION TO HEALTH POLICY IN THEEUROPEAN UNION
Bengt JönssonStockholm School of Economics
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ARE STAKEHOLDERS REALLY INTERESTED IN ECONOMICEVALUATION?
• Patients?• Doctors?• Managers?• Providers of goods and services?• Politicians?• Health economists!!!
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THE ROLE OF ECONOMIC EVALUATION: PROTECTING THEMEDICAL COMMONS
Protecting the Medical Commons: Who is responsible?Howard H. Hiatt.(NEJM 1975;293:235-241)
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WHAT CRITERIA TO USE FOR ASSESSING THE CONTRIBUTION?
• Are economic evaluations addressing important issues in allocation of resources for health and health care?
• Has the undertaking and publication of a growing number of economic evaluations contributed towards a more appropriate –i.e. more efficient and equitable health care
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CONCLUSIONS
• Health policy is increasingly focused on priorities for resource allocation
• Economic evaluation asks the relevant questions about value for money
• Development of methodology and building of competence to meet demands
• Data is an issue, but growing interest in real world data will support economic evaluation
• Implementation is key to improved contribution• Health care systems increasing involvement in innovation is
a major challenge for the future
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Kenneth Arrow:ECONOMIC WELFARE AND THE ALLOCATION OF RESOURCES FOR INVENTION (1962) Uncertainty and the welfare economics of medical care (1963)
• Third party (public) payment is necessary, but there are problems– Asymmetric
information– Moral Hazard– Adverse selection
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Alan Williams:COST-BENEFIT ANALYSIS: BASTARD SCIENCE AND/OR INSIDIOUS POISON IN THE BODYPOLITICK? (1972)
• I take the objective of cost-benefit analysis to be to assist choice –not to make choice, not to justify past choice, nor yet todelay matters
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Mobilisation of resourcesMobilisation of resources
Until the 1970s focus was on expansion of resources and access
Structure and processesStructure and processes
After the oil price chock, re-organisation (re-invention) was the solution to improvement in access
OutcomeOutcome
Today health care management focus on outcome and cost-effectiveness;Health and quality of care
SHIFT IN HEALTH POLICY TOWARDS IMPROVEMENTS IN OUTCOME
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INCREASING PUBLIC EXPENDITURES FOR HEALTH CAREHEALTH CARE COSTS AS SHARE OF GDP IN SWEDEN
0
2
4
6
8
10
12
1900 1950 1975 1980 2000 2010 2015
Procent
Procent
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ANNUAL GROWTH IN PER CAPITA HEALTH SPENDING
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The source of the matter – Appropriateallocation of scarce health care resources
• Dynamic efficiency– Adaption and diffusion
of new medicaltechnologies
– Optimal incentives for innovation
• Static efficiency– Over-consumption– Under-consumption– Low productivity
• ”Inside the frontier”
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INNOVATION AND EFFICIENCYCREATIVE CHALLENGE AND DESTRUCTION OF EXISTING PATTERNSOF CARE
O2O2AO1
O1A
ResourcesR
P1
P2
Outcome
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INNOVATION AND ECONOMIC EVALUATIONCANCER AS AN EXAMPLE
• Comparator Report on Patient Access to Cancer Medicines in Europe Revisited– http://ihe.se/filearchive/2/2651/IHE%20Report%202016_4_.pdf
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NEW OPPORTUNITIES CREATES MORE ALTERNATIVES“THE NEED TO CHOOSE”
0
10
20
30
40
50
60
1996‐2000 2001‐2005 2006‐2010 2011‐2015
Approved
substances
Year of approval
Chemo Hormon Targeted Immuno
Source. EMA (2016)
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RATIONALE FOR TAKING A EUROPEAN PERSPECTIVEONE MARKET BUT MANY HEALTH CARE SYSTEMS WITH SIMILAR NEEDSAND GREAT DIFFERENCES IN HEALTH CARE SPENDING
http://ec.europa.eu/eurostat/statistics-explained/index.php/File
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Diapositiva 15
BJ1 Table on EU health care expenditures pleaseBengt Jönsson; 14/09/2016
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COMPARISON OF DISEASE BURDEN
References: Jönsson B et al. Comparator Report on Patient Access to Cancer Medicines in Europe, Revisited. 2016. Available at: http://www.ihe.se/access-to-cancer-medicines-in-europe.aspx. Accessed September 2016.
HM1
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Diapositiva 16
HM1 Note to artwork, please adapt this infographic in-line with the slide design/themeHelena Mann; 12/09/2016
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0
5
10
15
20
25
30
Netherlands Spain Sweden
Cancer 00Cancer 12CVD 00CVD 12
RELATIVE BURDEN OF CANCER AND CVD IN 2000 AND 2012PER CENT OF TOTAL BURDEN MEASURED BY DALY
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CHANGES IN THE COMPOSITION OF TOTAL CANCERCOSTS
Components of the total cost of cancer in the EU (in billion €; 2014 prices), 1995–2014. Notes: Cancer is defined as ICD-10C00-D48 for health expenditure and ICD-10 C00-97, B21 for production loss due to premature mortality. EU = European Union; h-exp= health expenditure on cancer; m-loss = production loss due to premature mortality from cancer during working age.
References: Jönsson B et al. Eur J Cancer 2016; 66: 162–170.
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LARGE VARIATION IN UPTAKE BETWEEN RICHER AND POORERCOUNTRIES EVEN FOR DRUGS THAT HAVE DRAMATICALLYCHANGED OUTCOME (EXAMPLE: CML)
0
100
200
300
400
500
600
700
LowerGDP/capita
tier
MidGDP/capita
tier
UpperGDP/capita
tier
LowerGDP/capita
tier
MidGDP/capita
tier
UpperGDP/capita
tier
2005 2014
DDD pe
r case
imatinib dasatinib nilotinib
Source. IMS MiDAS
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LARGE DIFFERENCE BETWEEN COUNTRIES WITH SIMILARECONOMIC STRENGTH (EXAMPLE: CML)
0
5000
10000
15000
20000
25000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
€pe
r case
France Germany Italy Spain UK
Source. IMS MiDAS
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SALES OF CANCER MEDICINES 2014THOUSANDS EURO PER 100 000 INHABITANTS
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BETTER DECISIONS WITH THAN WITHOUT ECONOMIC EVALUATION
• Process matters– The fact that an economic evaluation is undertaken means
that relevant issues for the decision are put on the table, discussed and communicated
• Methodology and data matters as well– Inadequate method and data can miss-lead the decision
process– But it should be remembered that the economic evaluation is
a tool not a rule– Input to a deliberate process
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THREE KEY RESEARCH ISSUES
• Theory and methodology• Quality of data and practice• Implementation and impact
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RESEARCH ON METHODOLOGICAL ISSUES
• Cost-benefit versus cost-effectiveness• Social versus payer perspective on costs• Inclusion and calculation of indirect costs
– Friction method• Inclusion of costs in added years of life• Confidence intervals for cost-effectiveness ratios• Probabilistic sensitivity analysis• Choice of discount rate for costs and effectiveness• Inclusion or exclusion of VAT
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Alan Williams:ECONOMICS OF CORONARY ARTERY BYPASS GRAFTING. BRITISH MEDICAL JOURNAL, 1985, 291(6491): 326-329
• Selected the most important paper published in health economics during 25 years (1972-1997)
• Establishing the QALY concept
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RESEARCH ON QALY
• Inclusion of distributional objectives– equity- weighted utility maximization– testing the validity of underlying
assumptions• Disease specific QALY• Willingness to pay for a QALY
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ECONOMIC EVALUATION AND THE NEW CONCEPT OF VALUEBASED HEALTH CARE – THE NEW PUBLIC MANAGEMENT
• Value according to Porter– Outcome divided by payment/cost– Looks to me like cost-effectiveness
• Mechanisms for achieving value– Definition of relevant outcomes– Collecting data on outcomes and resource use– Bundle payments and competition
• Importance for economic evaluation– Improving external validity of data and creates link to
implementation
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TRIAL BASED VERSUS MODEL BASEDECONOMIC EVALUATIONS
• Ramsey SD, Willke RJ, Augustovski F, et al.– Cost-effectiveness
analysis alongside clinical trials II—an ISPOR Good Research Practices Task Force report. Value Health 2015;18:161–72.
• Editorial• Clinical Trials Provide
Essential Evidence, but Rarely Offer a Vehicle for Cost-Effectiveness Analysis– Marc Sculpher, York
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POLICY INITIATIVES AT THE EUROPEAN LEVEL WITH OPPORTUNITIESTO IMPROVE ECONOMIC EVALUATION
• IMI – BD4BO– Linking drug development to health outcomes
• Early joint regulatory-HTA advice– Improve external validity of clinical trial data
• Adaptive licencing– Optimizing the drug development process
from both a clinical and payer perspective
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LINK TO AND IMPACT ON DECISION MAKINGESTABLISHMENT OF COMPETENT AUTHORITIES
The Dental and Pharmaceutical Benefits Agency, TLV, is a central government agency whose remit is to determine whether a pharmaceutical product or dental care procedure shall be subsidized by the state.
Swedish National Board of Health and Welfare National Guidelines: are a support for those who make decisions concerning the allocation of resources withinHealth and Medical Care and Social Services. The goal of these guidelines is tocontribute towards patients and clients receiving a high standard of medical care
and social services
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SWEDISH HEALTH ECONOMISTS
• All • Working for government
• TLV 34%• National Board of Health
and Welfare 34% • SBU 15% • Ministry of Health 5% • Public Health Institute 4% • Other agencies 8%
35%
16% 15%
34%
Medical industry
County councils
Government
Academia and consul ng
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Right decision is necessary but not sufficient
Information/EvidenceHTA/econmic
evaluation
Information/EvidenceHTA/econmic
evaluation
ImplementeringFollow up
ImplementeringFollow up
DecisionPriorities/Guidelines
DecisionPriorities/Guidelines
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IMPLEMENTATION AND IMPACT. SOME NEW ISSUES
• Economic evaluations performed very early in the development of new technologies– New cancer medicines as example– Cost-effectiveness driven by pricing
• Management of uncertainty– Coverage by evidence development– Pay for performance
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• Relative effectiveness and cost-effectiveness have emerged the guiding principles for resource allocations
• Economic evaluations will increasingly be based on cost and outcome data from clinical practice
• Economic evaluation as an instrument for managing the early introduction of new, expensive end-of life technologies is a new challenge
CONCLUSIONS – DOING BETTER ANDFEELING WORSE
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