1 Disinvestment, a dégustation: Steps to success; Australia; The ASTUTE Health Study Adam Elshaug, MPH, PhD NHMRC Sidney Sax Fellow Department of Health Care Policy, Harvard Medical School, Boston, USA School of Population Health, The University of Adelaide, Australia Inaugural Visiting Fellow The Commonwealth Fund, New York, USA Special Advisor Comprehensive Management Framework of the Medicare Benefits Schedule Australian Government Department of Health and Ageing CAHSPR Conference May 2013 Vancouver
Five steps to success (?) 1. Resourced, formal agenda (breadth/depth buy-in) 2. Identify + prioritize candidates for review (process) 3. Capitalize on existing policy processes (dove-tail) 4. Broaden the evidence : Expect uncertainty but do not be paralyzed by it (action) 5. Know your context and target effective levers (impact)
Five steps to success Identify and prioritize candidates for review (process) 3 LISTS Structured process Transparent High sensitivity; Low specificity (clinical input) NICE Do not do ABIM Choosing Wisely Elshaug 150+ candidates USPSTF D recommendations
Point of Prioritisation 4 Cost (per procedure or volume) = Budget impact Variation (x3: Geographic, Provider, Temporal) Impact (health, disutility, liberation, equity) Cost-effective alternative/s Burden (high/low) Strength of evidence: (un)certainty Futility Precedent Levers for effecting change are apparent Elshaug A, et al. Medical Journal of Australia. 2009 Mar 2;190(5):269-73.
Five steps to success Capitalize on existing policy/hta processes 5 Identify and prioritize individual services for HTA Australia (federal); Spain; England (NICE); Canada; US CER; Denmark, Norway; Sweden; Scotland; Ontario Target whole-of-specialty areas (HTA) Australian Medicare (Federal) Target disease groups (multiple specialties in pathway) All countries through guidelines; US CER - AHRQ. Disinvestment sp: England (NICE guidelines); Netherlands Manage entire programme budget (marginal analysis) British Columbia; UK (PCTs); Spain/Basque Australian states
Five steps to success Expect uncertainty be thoughtful but decisive (action) 6 AUSTRALIA: 2006: Vertebroplasty placed on interim funding pending further evidence generation 2009: Two RCTs published in NEJM demonstrating no benefit over conservative management 2011: Vertebroplasty removed from Australia s FFS Medicare Schedule
Defining low-value for whom, when, with what confidence? High and Low Value Applications X High-value procedures Low-value procedures Low-hanging fruit Skinner and Chandra typology of medical technologies with heterogeneous benefits. Costs of treatment are assumed to be constant across and within categories. Adam Elshaug, 2013
Five steps to success Know your context and target effective levers (impact) 8 Fee-for-Service (Australian Medicare; Ontario) Delist; Refine patient indications; Refine fee; Restrict ordering (by specialty); Limit quantity Guidelines and Education (NHS via NICE; USA) Build-in inappropriate use guidance Rank options within Programme Budget (BC) State, regional and hospital budgets (PBMA)
9 Some examples
(Australian) MBS Quality Framework Parallel Approach using HTA: 1. Review of individual items Safety, effectiveness, CE (with comparator/s) 2. Whole-of-specialty review Ophthalmology
(Australian) MBS Quality Framework Parallel Approach using HTA: 1. Review of individual items Safety, effectiveness, CE (with comparator/s)
Ophthalmology Review Results 61 item (fee-for-service) descriptors 41 out of 61 item descriptors were: Clarified (intervention) Modified (refining indications/eligible patient groups); Split; Merged; or Entirely removed (n=7) Acknowledgement to Tracy Merlin, AHTA Merlin T, et al. (2011) Review of MBS Items for specific ophthalmology services under the MBS Quality Framework. Canberra, ACT: Commonwealth of Australia.
A case study NICEly done Thornhill MH et al. Impact of the NICE guideline recommending cessation of antibiotic prophylaxis for prevention of infective endocarditis: before and after study. BMJ. 2011 May 3;342:d2392. Acknowledgement to Dr. Sarah Garner, NICE
Upper airway surgery for obstructive sleep apnoea 40% reduction after first year of HTA-driven reforms * Revised clinical guidelines * Regional Hospital Boards reimbursements for surgery * Directorate of Health adjusted the DRG rate for surgery Acknowledgement to Dr Berit Mørland, Norwegian Knowledge Centre for the Health Services Secretariat - Norwegian Council for Priority Setting in Health Care; and SBU
Learning from Prospect Theory Broaden evidence base Stakeholders Payers and Regulators (with industry, via HTA) Inputs Safety Efficacy Effectiveness Value Results Investment Payers, regulators, industry, clinicians, HTA, professional societies, patients, safety & quality bodies, employers, academics, media Safety Efficacy Effectiveness Value and values Resistance Politics Sunk costs Disruption; unintended consequences Loss aversion Innovation head room Uncertainty and a higher burden of evidence Elshaug et al. Challenges in Australian policy processes for disinvestment from ineffective health care practices.. Aust NZ Health Policy 2007 Disinvestment 15
NHMRC-funded ASTUTE Health study, 2009-13 CIs: Janet Hiller, Adam Elshaug, Annette Braunack-Mayer, John Moss, Janet Wale, Heather Buchan AIs: Tracy Merlin, Jonathan Karnon, Jackie Street, Robert Wells, Peter Littlejohns, clinical collaborators Researchers: Cameron Willis, Amber Watt, George Mnatzaganian, Drew Carter, Dagmara Riitano, Katherine Hodgetts Aim: to trial and evaluate a model to refine the indications for resource allocation to ineffective or inappropriately applied health care practices. Deliberative Engagements: Patient; Community; Clinical; Policy Two case studies: Assisted Reproductive Technologies (ART) B12/Folate tests
ASTUTE Health study: Implications for disinvestment Evidence frequently lacking for disinvestment in HTA terms Need for widespread engagement around protocols + evidence gaps Engagement with patients and the tax payer is invaluable Recognize opportunity costs; Supportive of need for allocative efficiency; Dispelled fears and misconceptions re: unreasonable expectations of masses Nuanced solutions, + unintended consequences, + equity implications Tolerance for over servicing in grey zone tragedy of the commons? Particular challenges in obtaining data to inform cost effectiveness analysis with unreliable and missing effectiveness and other data to inform models Evidence paradox: Higher burden for reversal than exists for initial funding Onus on clinical/research communities to fill gaps MERIT CAPACITY TO BENEFIT RIGHTS NEED
18 thank you questions elshaug@hcp.med.harvard.edu