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Contribution of innovative approachesContribution of innovative approaches to health systems’ sustainability:

Health Technology Assessment and Chronic Disease ManagementChronic Disease Management

Reinhard Busse Prof Dr med MPH FFPHReinhard Busse, Prof. Dr. med. MPH FFPHDept. Health Care Management, Berlin University of Technology

(WHO Collaborating Centre for Health Systems Research and Management)&&

European Observatory on Health Systems and Policies

Needs-based Personnel well qualified?Institutions of high standards?

High-qualityresults?access? Institutions of high standards?

Technologies effective?results?

Transparent?

Oth t

Nutrition/ agriculture

Environment

Population health status ( d)

Other sectors

Health care outcome:

satisfaction,

Patients: demand, access

Process

(need)

Health gain/Human

complica-tions etc.Structures

and organisation

Process gain/ Outcome

Human resources

Techno-Health care systemlogies

Financial

Patients receivingappropriate services?

How much?Is it worth it?

resources

Professional (re-)certificationProvider (re-)accredition

“Do the thing right“:

Universal coverage,appropriate

Health Technology AssessmentConcentration of services

Registers; benchmarking

entitlements, limited cost-sharing

Nutrition/ agriculture

Environment

Population health status ( d)

Other sectors

Health care outcome:

satisfaction,

Patients: demand, access

Process

(need)

Health gain/Human

complica-tions etc.Structures

and organisation

Process gain/ Outcome

Human resources

Techno-Health care systemlogies

Financial

“Do the right thing“: ex ante Disease managementprogrammes/ guidelines/ reminders; ex post Review

resources

“The goal of HTA is to g fprovide input to decision making in policy and

Patientwishes making in policy and

practice“ (Henshall et al. 1997)

IF somebody asks!Industry claims

Provider – IF somebody asks!Providerpreferences

HTA and PolicyH ( th d l )?

HTA and Policy How (methodology)?

Who? Relevance of HTAvs. other influences?

EUnetHTA | European network for Health Technology Assessment | www.eunethta.eu

Wh t? ”T h l i ” i hTTh i t ti (d d

What? ”Technologies” in hTa The interventions (drugs, procedures,

complex multidisciplinary activities) which can be provided / reimbursed within the system when deliveringwithin the system when deliveringhealth services

The interventions applied to the system to organize service delivery accessto organize service delivery, access, financing, payment of providers, etc.


An examplep

Practical Purposeimproving survival after myocardial infarction“„improving survival after myocardial infarction

Technologies Aspiring pStentE l h bilit tiEarly rehabilitation

Disease Management ProgrammeDisease Management ProgrammePayment for Performance


Health Technology Assessment:gyEfficacy vs. Effectiveness

EfficacyEfficacy• explanatory trials

EffectivenessEffectiveness• pragmatic trialsp y

• highly selected populations

p g• few exclusions• comparator: ‘current

• comparator: placebo• outcomes: clinical,

p(best) practice’

• outcomes: patient-morbidity, mortality, adverse effects

focused, down-stream resources

E id GEvidence Gap• ‘what it says on the packet

• ‘the real life effect’Evidence GapEvidence Gap


Role of HTA within ”knowledge value chain”


Other types of evidenceOther types of evidence


Technologies and the ”knowledge value chain”

ons

terv

entio

pes

of in

Oth

er ty

pO


Broad HTA InstitutionsBroad HTA Institutions


Impact?Impact?


• Policy processes and HTA

• Health systems, ea t syste s,health policy and HTA

• HTA producersHTA producers• Impact of HTA

N d d d d• Needs and demands of policy-makers

• Future challenges for HTA in Europe

www.euro.who.int/observatory

Di tDisease management programmes: key elementsy

• comprehensive care: multidisciplinary care for entire disease cycledisease cycle

• integrated care, care continuum, coordination of the different componentsdifferent components

• population orientation (defined by a specific condition)i li i l (h l h• active client-patient management tools (health

education, empowerment, self-care)id b d id li l h• evidence-based guidelines, protocols, care pathways

• information technology, system solutions • continuous quality improvement

DMPs are popular – at least in Germany whereDMPs are popular – at least in Germany, wherethey were tied to financial incentives until 2008

DMP Number of patients enrolled in DMP 2008DMP 2008

Diabetes mellitus type 2 2,708,154i b lli 1 93 3Diabetes mellitus type 1 93,357

Coronary heart disease 1,221,374Asthma 313,914COPD 264,299Breast cancer 100,499Total 4,701,597 (7% of all insured)

DMPs: How effective?• Crucial and weak point!• Most publications report on relatively small-

scale interventions without control group or g pinadaequate control (e.g. no randomization, no risk adjustment)j )

• (As for pharmaceuticals etc.:) the weaker the study design the larger the published effectsstudy design, the larger the published effects

• Logic of Evidence-based Medicine applies: best available evidence countsbest available evidence counts

How effective are Disease Management Programmes?

Mattke et al. Am J Manag Care. 2007; 13: 670-676

DMPs: how costly and how cost-effective?effective?

• Even less published evidence; if costs are t d i l ti th th d l ireported in evaluations, the methodology is

usually flawed!• On macro-economic implications, we have

to rely on models and projections!y p j• Managing CD costs additional money

(-> not effective for cost-containment in( > not effective for cost containment in short run),but may be cost-effective (data missing!)but may be cost effective (data missing!).

DMPs are only one component of dealing with chronic disease

managementmanagementBurden of Chronic Disease CDM Strategies Dimensions of CDM

Epidemiologic Burden

Prevention and Early DetectionNew Pharmaceuticals and Medical

Devices

KulturwissenschaftenFinancial IncentivesNew Provider and Qualifications

Kulturwissenschaften

Cooperation and Coordination

Disease Management Programmes

Economic Burden

Information and Communication Technology

Integrated Models of Care Evaluation Culture

20

Shaping the future of managing chronic diseases in Europe

• New pharmaceuticals and medical devices may help toNew pharmaceuticals and medical devices may help to improve CD -> but critical assessment regarding patient benefit, based on accepted methodology, crucialbenefit, based on accepted methodology, crucial

• Right mix of financial incentives very important (for insured/ patients payers providers )insured/ patients, payers, providers …)

• Strengthen coordination (in access, orientation, provision of information continuity/coordination/communicationof information, continuity/coordination/communication among professionals)

• Elaborated information and communication technologies• Elaborated information and communication technologiescrucial, but agreement on international technical stabdards necessarynecessary

• Establish evaluation culture without exceptions

Weaknesses of traditional ways of paying providers for chronic careproviders for chronic care

Fee-for-service CapitationCase payments

* Ill patientsusually attractive* Overprovision

* Ill patientsnot attractive* Underprovision

* Very ill patientsnot attractive* Tendency to* Overprovision

of services* Underreferral

* Underprovisionof services* Overreferral

* Tendency toaverage provision* Weak quality Underreferral

* No incentive forhigh quality

Overreferral* Quality: bad results-> more work

Weak qualityincentives

* No incentives for appropriate continuity of care across providers

Examples of new payment measuresExamples of new payment measures• ‘year of care’ payment for the complete service

k i d b i di id l i h h ipackage required by individuals with chronic conditions (DK)

i b f h i i f i• per patient bonus for physicians for acting as gatekeepers for chronic patients and for setting care protocols (F)protocols (F)

• bonus for DMP recruitment and documentation (D)1% f ll h l h b d il bl f i d• 1% of overall health budget available for integrated care (D)b i f hi l d• boni for reaching structural, process and outcome targets (UK)‘ f f ‘ b i (US E )• ‘pay-for-performance‘ boni (US -> Europe)

Chronic patients‘ cost-sharing –traditional approachestraditional approaches

t f i l t d t th i• no co-payments for services related to their disease, e.g. ‘ALD’ (30 mainly chronic diseases) in France

• lower annual limits on co-paymentslower annual limits on co payments• certain drugs require lower cost-sharing if the

indication is deemed serious

Chronic patients‘ cost-sharing –newer approachesnewer approaches

• ‘ALD’ exemption only if care protocol is establishedfor each patient by their GP and signed by patientfor each patient by their GP and signed by patient(France since 2004)

• cost-sharing may be reduced or waived if patientsenrol in DMPs

• patients with chronic conditions/complex needsmanaged via a care plan/ inscribed in DMP receivemanaged via a care plan/ inscribed in DMP receiverebates (Australia) or additional services (Germany)

• ‘ALD’ exemption only if protocol is presented toevery treating physician at each visit (France)

• lower cost-sharing limit applies only if patientis compliant (Germany since 2007)

Evaluation culture• Many aspects of managing chronic disease are not

properly evaluated -> effectiveness and cost-properly evaluated -> effectiveness and cost-effectiveness of various prevention and treatment interventions not well establishedinterventions not well established.

• Policy-makers are therefore not best equipped to make informed “HTA” decisionsinformed HTA decisions.

-> Policy-makers must ensure that evaluationybased on rigorous methodology is an integralpart of all strategies.p gExisting data should be made available forresearch and review across differenttechnologies, settings and providers.

This presentation and more material canThis presentation and more material can be found on the following websites:g

htt // i t b li dhttp://mig.tu-berlin.de

www.euro.who.int/observatorywww.euro.who.int/observatory

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