health technology assessment program senate health care committee november 20, 2014 josh morse, mph,...
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Health Technology Assessment ProgramSenate Health Care Committee
November 20, 2014
Josh Morse, MPH, Program Director, Health Technology Assessment
Daniel Lessler, MD, Chief Medical OfficerCharissa Fotinos, MD, Deputy Chief Medical Officer
PurposePrimary purpose:
To ensure medical treatments and services paid for with state health care dollars are safe and proven to work.
The program: Is a resource for state agencies purchasing health care. Develops scientific, evidence-based reports on medical
devices, procedures, and tests. Facilitates the independent clinical committee of health care
practitioners to determine which medical devices, procedures, or tests meet safety, efficacy, and cost tests.
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Program Background• In 2006 HB 2575 created the HTA program in Chapter 70.14 (Public
Health and Safety, Health care purchased by state agencies)• Structured to use an evidence report and a clinician panel to make
coverage decisions about whether agencies should pay for certain medical, devices, procedures and tests based on: Safety Efficacy/effectiveness, and Cost-effectiveness
• HCA established the program and staffs the committee• Multiple agencies participate to identify topics and implement
policy decisions: HCA (Uniform Medical Plan, Medicaid) Dept of Labor and Industries Dept of Corrections
• Implementation: Agencies implement determinations of the HTA program within
their existing statutory framework. 3
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Why Health Technology Assessment?
The development and diffusion of medical technology are primary factors in explaining the persistent difference between health spending and overall economic growth.
New medical technology may account for about one-half or more of real long-term spending growth. Kaiser Family Foundation, March 2007: How Changes in Medical Technology Affect Health Care Costs
Since technological change is the biggest contributor, an effective long-term strategy for controlling health care spending will probably have to address the health care system’s way of incorporating new technologies into practice.U.S. Congressional Budget Office, Technological Change and the Growth in Health Care Spending, 2008. Report available at www.cbo.gov.
Medical technology diffusing without evidence of improving quality. Highly correlated with misuses, overutilization, underutilization. Cathy Schoen, Karen Davis, Sabrina K.H. How, and Stephen C. Schoenbaum, “U.S. Health System Performance: A National Scorecard,” Health Affairs, Web Exclusive (September 20, 2006): w459
Regulatory Framework: Drugs vs Devices/Procedures
Drugs Medical Devices Procedures
Required for FDA Approval
2 prospective, placebo controlled
RCTs
“Substantial equivalence” to
preexisting device
No approval requirements
Study Outcomes Disease-related endpoints
Engineering performance only
None
Published Studies with Patient Outcomes
Common Uncommon Not Considered
Post-market Evaluation?
Narrowly defined set of conditions (e.g., depression,
dementia)
Varies widely (e.g., implantable
defibrillators, laparoscopes)
Not Considered
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WA HTA Process Topic Selection
State agencies identify technologies for review– Horizon scan for new technologies– Agency needs and experience with new or existing
technologies inform selection Prioritize technologies HCA Director makes final selection Interested parties may nominate topics
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WA HTA Process Topic Selection
Primary criteria are directly linked to the legislation :1. Potential patient harm/safety concerns
The safety criterion is directed at identifying the potential degree of harm that an individual may experience if the technology is used.
2. Concerns about therapeutic efficacy or diagnostic accuracy and appropriateness of outcomes for patients
The efficacy criterion is directed at identifying whether there are issues related to the potential clinical impact that the technology, if used, can have for the individual with the condition indicated – including consideration of:
Range of potential benefits Treatment alternatives Realized benefits
3. Estimated total direct cost per year (estimated increase/decrease) The cost criterion is directed at identifying the potential budget impact (degree of
change) that the technology coverage or non-coverage would have for the participating agencies.
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WA HTA Process Overview
Agencies Implement DecisionImplements within current process unless statutory conflict
Clinical Committee makes Coverage DeterminationReview report, Public hearing Meets quarterly
Vendor Produces Technology Assessment ReportKey Questions and Work Plan, Draft, Comments, Finalize 2-8 Months
HCA Director Selects TechnologyNominate, Review, Public Input, Prioritize Semi-Annual
Key HTA Products
• Transparency: Publish topics, criteria, reports, open meetings
• Technology Assessment Report: Formal, systematic review of selected technologies
• Independent Coverage Decision: Committee of clinicians makes decisions that are based on the science, transparent, and consistent for state programs
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• Technology Reports: Analyses completed 47 comprehensive technology assessment reports 6 in process
• Coverage Decisions 47 health technologies reviewed for coverage
determinations Estimated >$48 million cost avoided (annual)
• Transparent Processes Topics, Key Questions, Draft Reports, Final Reports,
Criteria Posted More than 100 days of public comment period per
technology Committee reviews in public meetings – all
deliberations open
Process MeasuresDecision Results
Covered (no conditions) 2% (1)
Covered with Conditions 63% (41)
Not Covered 35% (23)
Recent HTA Process Updates
• Extended draft review/comment period for technology reports from 14 to 30 days (2012)
• Expanded background information with selection of new topics (2014)
• Adding meeting for new topic information and context (2014)
• Revised order of presentations to HTCC in public meetings (2014)
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Measurement: Dollars and Quality
• Challenging to accurately assess impact:– Units and cost are most accessible
– Quality and safety more difficult to quantify
• Current method is to estimate cost avoidance
• Working to conduct formal evaluation of program impact
HTA Estimated Cost Avoidance
• Projection of how future expenditures will change based on:– Health Technology Clinical Committee decision – Agencies’ utilization
Published within the evidence report for agencies:PEB/UMPMedicaidL&I
• Estimated using – actual agency costs (does not include reduction in
harms to patients or other speculative changes)– published rates and costs when agency experience
is absent (e.g. Pediatric Bariatric surgery based on adult costs, childhood obesity rates)
Cost Avoidance Conservative Estimates
Estimate based on actual costs and trends with conservative assumptions
– No growth or conservative growth figures based population adjusted averages (e.g. Spinal Injections)
– Moderate estimates of effect - 50% of best estimate (e.g. Upper Endoscopy for GERD)
5% growth used in estimate
L&I 6% Growth
UMP/PEB 12%
Growth
Medicaid 16%
Growth
Spinal Injections Estimate: Growth
HTA Program Summary 2007-2014
Technologies Coverage Decisions Costs Avoided
Year Topics Decisions Yes NoEstimate
(single year)
2007 3 4 2 2 ($8.8M)
2008 6 7 3 4 ($17.5M)
2009 6 6 4 2 ($1.9M)
2010 7 9 6 3 ($3.5M)
2011 6 11 6 5 ($5.4M)
2012 7 10 7 3 ($2.6M)
2013 8 11 10 1 ($7.7M)
2014 5 5 4 1 ($1.1M)
Total 48 63 42 21 (48.3M)
Questions?
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Daniel Lessler, MD, Chief Medical [email protected]
Charissa Fotinos, MD, Deputy Chief Medical [email protected]
Josh Morse, MPH, Program Director, Health Tech [email protected]
Phone: 360-725-1893