‘You say HTA, I say CER’: international perspectives on evidence-based health policy

Terms such as ‘evidence-based health policy’, ‘comparative effectiveness research’ (CER) and ‘health technology assessment’ (HTA) are no longer restricted to discussions among health economists – they have become household topics.

But are people defining them differently? Or are we all unwittingly speaking the same language? After all, George Bernard Shaw once described America and England as two countries separated by a common language. For health economists (or any other interested persons) seeking to understand healthcare systems outside their own country, there are several, recently available resources:

The Milbank Quarterly recently published an article (Chalkidou K et al. 2009;87(2)) analysing CER and evidence-based health policy in four countries: Britain, France, Australia and Germany. The authors, who are employed by each of the four countries’ HTA/CER entities, as well as the Center for Medical Technology Policy in the USA, interviewed key stakeholders in CER entities in each country, as well as reviewed the agencies’ web sites and legal framework documents. This article was designed to provide a ‘lessons learned’ summary for the USA as it works to develop its own CER, from other Western countries that use HTA/CER in their decision making.

Using 10 core attributes that capture the main aspects of the four HTA/CER agencies, Chalkidou et al concluded that while each country’s HTA/CER entity has developed HTA/CER unique to its own health system, each has adopted a core set of desirable procedural principles to ensure that the HTA/CER is relevant to each country’s healthcare system.

Overall, some of the key lessons learned are:

• HTA/CER should be a demand-driven entity (ie, relevant to its stakeholders and not merely an academic pursuit);
• Negative press coverage and intense controversy are par for the course (and indeed indicate that the HTA/CER entity is fulfilling its role); and
• The three ingredients for success are strong political endorsement, early engagement of stakeholders, and commitment to evidence-based practices to gain professional approval.

For a more academic discussion of differences in HTA, check out Claude Le Pen’s editorial in the European Journal of Health Economics (2009;10;121-123), in which he compares the philosophical differences in social contracts underlying Britain’s NHS and France’s Sécurité Sociale.

An interview with Dr Naoki Ikegami in Expert Review of Pharmacoeconomics & Outcomes Research (2009;9(3):201-204) provides some insights into the Japanese healthcare system, especially in comparison with the UK’s NHS and NICE.  Dr Ikegami is Professor and Chair of the Department of Health Policy and Management at Keio University School of Medicine. However, he offers international expertise to his perspective as he received a Master of Arts degree in health services studies with Distinction from Leeds University and was a visiting professor at the University of Pennsvlania’s Wharton School of Business and Medical School.

Shishkin and Vlassov discuss the need for modernisation of Russia’s healthcare system in the British Medical Journal (BMJ 2009;338:b2132). They describe the recent reforms as Russia transitioned to a market economy and the proposed reforms through 2020.

Finally, the ISPOR (International Society for Pharmacoeconomics and Outcome Research) website provides a detailed description of many countries’ health care systems (the Global Health Care Systems Road Map), including processes for pricing and reimbursement, and health technology assessment (HTA, referred to as comparative effectiveness research [CER] in the USA).

The website also provides access to papers from a special issue of Value in Health — Health Technology Assessment in Evidence-Based Health Care Reimbursement Decisions Around the World: Lessons Learned (June 2009;12(s2):S1 – S53).

Greenflint, the sister company to Rx Communications Ltd, understands the challenge faced by health economists in helping people to understand what comparative effectiveness research and evidence-based medicine really are – in language that people who are not directly involved with these disciplines can readily understand.

Our booklet, Comparative Effectiveness and Evidence-based Medicine, doesn’t come from a health policy approach, however. We take a more practical standpoint, by helping the reader understand how and when these methods are applied, and their uses, limitations and applications to healthcare provision. In addition, we’ve designed the content so that you can add your own company examples and perspectives into the text to make it relevant to your own audience.

If you would like to see a copy of this booklet, please go to our website or contact either Steve Handley or Ruth Whittington at Rx Communications Ltd for more information.

Using Medicare Data to Understand Growth in US Healthcare Costs

By Mary Gabb (marygabb@rxcomms.com)

Researchers from the Dartmouth Atlas Project suggest that regional variations in per capita Medicare spending provide important clues for how to more efficiently deliver healthcare throughout the United States, such that Medicare could shift from being insolvent (as projected) to being solvent by 2023.

With healthcare reform next on President Obama’s To Do list, the big question – after what it will look like – is how much it will cost. Julie P. Bynum, MD, MPH, along with Elliot S. Fisher, MD, MPH and Jonathon S Skinner, PhD from the Dartmouth Atlas Project, describe some ways that the growth rate – rather than the actual costs — of US healthcare can be controlled, to “bend the cost curve.”

As Dr Bynum explains, it’s not just a matter of absolute dollars and cents: “A lot of people focus on cost and cutting cost, and we were trying to focus on growth.”

The Dartmouth Atlas Project data show that overall Medicare spending (adjusted for general price inflation) rose by 3.5% annually, from 1992 to 2006. The annual growth rate for Salem, OR was lower than the national average (2.3%) while in Miami, FL the growth rate was 5%, yet Miami had some of the highest total per capita spending. The highest growth rate nationwide was in McAllen, TX (8.3%), compared with Honolulu, HI, which boasted the lowest growth rate (1.6%).

Changes in healthcare costs based on Medicare reimbursements, 1992 to 2006, by hospital region

How much does a few percentage points matter? According to their calculations, if annual spending growth was reduced from 3.5% to 2.4% (the rate in San Francisco), Medicare would be in the black by US$758 billion, instead of in the red (as currently projected) by $660 billion by 2023 – a cumulative savings of US$1.42 trillion dollars.

Why do these differences in growth rates exist? That’s the million – or trillion – dollar question and it most likely has many answers.

As Dr Bynum explains, “people have been very nihilistic about the costs in healthcare and about healthcare cost growth, attributing it to technology and saying if we want the best technology in medicine, we just have to absorb the cost. What we tried to show was, in fact, cost growth … is not inevitable…No one would argue that people in San Francisco are getting less of the technological care than people in Miami but their growth rates are remarkably different. So it’s really a message of hope. It can be done differently because it is being done differently.”

We’ll be talking with Dr Bynum and others about what some of these different healthcare delivery strategies look like.