dimensions of value, assessment, and decision making
TRANSCRIPT
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Adrian TowseDirector of the Office of Health EconomicsVisiting Professor London School of Economics
HTAi Tokyo May 2016
Dimensions of value, assessment, and decision making
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HTAi Tokyo May 2016
Agenda
• Identifying the elements of value • Methods of assessing value • Translation to price and affordability
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HTAi Tokyo May 2016
An overview of the process (1) A reordering of process?
SafetyEfficacy,
effectiveness
Value for money (CE)
Other factors of value to D-M
(ethical issues, social values, feasibility of
implementation, unmet needs,
innovation value, legal issues, …)
Affordability (BIA)
Criteria: broader definition of value (risks, benefits)
Overall D-M Framework: Opportunity costs (value-for-money)
Source: Ron Goeree, Director PATH Research Institute, Professor, McMaster University
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HTAi Tokyo May 2016
An overview of the process (2) Getting to Health System Value1
Comparative Clinical
Effectiveness
Additional Benefits & Context:Health System
Intervention Value
Affordability,
Incremental cost per
outcomes achieved
Decision making process
Health System Value
1Adapted with permission from Steve Pearson, ICER
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What elements of value? Usually recognised and Less frequently / consistently recognised
Usually recognised
• Health effects that are well captured
• Cost offsets
• Uncertainty
Less frequently / consistently recognised
• Health effects less well captured
• Wider societal impacts• Severity /unmet need• National Priorities • Process issues• Innovation• Patient preferences• The value of knowing
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HTAi Tokyo May 2016
What elements of value? Precision medicine
“..an approach to disease treatment and prevention that seeks to maximize effectiveness by taking into account individual variability in genes, environment, and lifestyle”1
• Enabling a treatment effective only in a small fraction of the population to be made available
• Reducing or avoiding the adverse effects associated with treatment (including the medical and nonmedical costs of managing them)
• Reducing or avoiding time delays in selecting the most appropriate intervention
• “Value of knowing”
1. President Obama’s Personalized Medicine Initiative
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HTAi Tokyo May 2016
What elements of value?Precision medicine – examples
A. Reduce or avoid adverse drug reactions
B. Reduce or avoid delay in
selecting optimal treatment
C. Increase patient
adherence or willingness to
start preventive interventions
D. Enable Tx with a small
proportion of responders to be made available
E. Value of Knowing
(i) Allows Tx to obtain licence based on Dx availability
Example:BCR-ABL in CML
Example: PreDx Diabetes Risk
(i) Tx has higher chance to obtain licence or to be
‘rescued’ with Dx.Example: EGFR
mutation in NSCLC
Example: Oncotype DX in breast cancer
(ii) Use of a licensed Tx is
increased with Dx.Example: HLA-B*
5701 in HIV
(ii) Increases Tx cost effectivenessExample: HER2 in
breast cancer
(iii) Dx supports clinical trials and hasten market approval of Tx.
Example: ALK Fish in NSCLC
Adapted from Garau et al. 2013
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HTAi Tokyo May 2016
What elements of value?The value of knowing
• Increasing the certainty of a patient’s response to a medicine
• “Knowing for the sake of knowing” (Asch et al., 1999)
• The value of hope (Lakdawalla et al., 2012)
• Real option value (Cook et al., 2011)
• Insurance value (Lakdawalla et al., 2015)
• Scientific spillovers
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HTAi Tokyo May 2016
Agenda
• Identifying the elements of value • Methods of assessing value • Translation to price and affordability
1
2
3
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HTAi Tokyo May 2016
Steps to “a decision on value”
What elements of value?
How measured, evidenced and valued
/rated?
How aggregated and judged?
A “decision on value”• Health effects• Well captured• Cost offsets• Uncertainty• Health effects that
are less well captured• Wider societal
impacts• Severity /unmet need• National Priorities• Process issues• Innovation• Patient Preferences• The Value of Knowing
• Measured: e.g. use of QALYs, clinical outcomes
• Evidenced: e.g. preference for RCTs
• Valued /rated: e.g. population or patient values, use of categories or discrete scales
• Challenges– Scientific
uncertainty– Value judgements
• Weighting:– Deliberative
processes– Algorithms
• How structured could /should this become?
– Avoid a “black box”
1 2 3
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HTAi Tokyo May 2016
Use of categories or discrete scales
ASMR rating
Definition
I Major therapeutic progress
II
Significant progress in terms of therapeutic efficacy and/or reduction in side effects
III
Modest progress in terms of therapeutic efficacy and/or reduction in side effects
IVMinor progress in terms of efficacy/usefulness
V No therapeutic progress
NICE• Does a
technology get assessed or not?
• Exemption / separate treatment of orphan drugs
• End of life threshold uprating and use for small patient populations
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A system not based on MCDA
MCDA converts all input evaluations of decision outcomes into a common currency of value added—not financial value, preference value
Source: Professor Larry Phillips London School of Economic and Facilitations Limited
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HTAi Tokyo May 2016
An MCDA example
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HTAi Tokyo May 2016
Results of weighting in the MCDA examplePer cent
‘Experts’ workshop
‘Patients’ workshop
Extent to which treatment is available in the absence of the new medicine 19.5 11
Disease’s mortality impact with current SoC 14 11.5
Morbidity and disability with the disease with current SoC 12 15
Impact of the disease on patients’ and carers’ daily lives with current SoC 8 15
Sub-total weight for impact of disease / extent of unmet need 53.5 52.5
Evidence of treatment clinical efficacy and patient clinical outcome 27.5 17.5
Drug safety 8 7.5
Social Impact of the treatment on patients’ and carers’ daily lives 11 17.5
Treatment innovation 0 5
Sub-total weight for impact of new medicine 46.5 47.5
Total 100 100
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HTAi Tokyo May 2016
Agenda
• Identifying the elements of value • Methods of assessing value • Translation to price and affordability
1
2
3
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HTAi Tokyo May 2016
Two main approaches to pricing
• cost-effectiveness requirements. Drugs are assessed for use or for a reimbursement price by looking at incremental health related effects (often measured and valued using the Quality Adjusted Life Year (QALY) and incremental costs relative to existing treatments using cost effectiveness analysis (CEA).
• therapeutic added value requirements. These typically involve comparison with other, established drugs in the same class, or with other treatments used in the standard of care (SoC) with higher prices allowed or negotiated for improved health or health related effects in the form of efficacy, better side effect profile or convenience.
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HTAi Tokyo May 2016
The England cost-effectiveness threshold saga
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HTAi Tokyo May 2016
Sweden: Equity /”need” adjusted reimbursement decisions compared with a constant cost-effectiveness thresholdCost/QALY
Source: Ulf Persson, IHE
Threshold
Adjusted threshold
Degree of severity/”need”0.5 1.00.90.1 0.2 0.3
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HTAi Tokyo May 2016
Use of categories or discrete scales to support different categories of pricing
ASMR rating
Definition
I Major therapeutic progress
II
Significant progress in terms of therapeutic efficacy and/or reduction in side effects
III
Modest progress in terms of therapeutic efficacy and/or reduction in side effects
IVMinor progress in terms of efficacy/usefulness
V No therapeutic progress
NICE• Does a
technology get assessed or not?
• Exemption / separate treatment of orphan drugs
• End of life threshold uprating and use for small patient populations
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HTAi Tokyo May 2016
Elements of value, assessment, and pricing– a summary
• Value extends beyond health gain and system cost savings
• No one way to scale, score, and weight• Decision support tools are essential
• Can convert value to price directly (ICERs and thresholds) or indirectly (TAV)
• Opportunity cost is important • But using a threshold is not easy• TAV with categories and discrete scales are an
alternative
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ReferencesAsch, D., J. Patton, and J. Hershey, 1990. Knowing for the sake of knowing: the value of prognostic information, Medical Decision Making 10, pp. 47-57.
Cook, J. P., J. H. Golec, J. A. Vernon, and G. H. Pink, 2011. Real option value and path dependence in oncology innovation, International Journal of the Economics of Business 18(2), pp. 225-238.
Garau, M., Towse, A., Garrison, L., Housman, L. and Ossa, D. (2013). “Can and should value-based pricing be applied to molecular diagnostics?” Personalized Medicine. 10(1), 61-72.
Garrison L., Mestre-Ferrandiz J, and Zamora B (2016 forthcoming). The Value of Knowing and Knowing the Value: Improving the Health Technology Assessment of Complementary Diagnostics. EPEMED
Lakdawalla,D. , Malani, A. and Reif, J. (2015). 'The Insurance Value of Medical Innovation', National Bureau of Economic Research Working Paper w21015
Lakdawalla, D. N., J. A. Romley, Y. Sanchez, J. R. Maclean, J. R. Penrod, and T. Philipson, 2012. How cancer patients value hope and the implications for cost-effectiveness assessments of high-cost cancer therapies, Health Aff (Millwood) 31(4), pp. 676-682.
Towse, A. and Barnsley, P. (2013). “Approaches to identifying, measuring, and aggregating elements of value.” International Journal of Technology Assessment in Health Care. 29(4), 360-364.
Towse, A. (2014). “Value of drugs in practice”. In A. Culyer ed. Encyclopedia of Health Economics. San Diego, CA, Elsevier. pp. 432-440.
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Adrian TowseThe Office of Health Economics
Registered address Southside, 7th Floor, 105 Victoria Street, London SW1E 6QT
Website: www.ohe.org Blog: http://news.ohe.orgEmail: [email protected]
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