Creating a cost effective and
sustainable health system using
an evidence base
Health Technology Assessment Conference
Ann...
Declarations of Interest
• Vocationally registered paediatric surgeon
• Chair, National Health Committee
• Director, Pharm...
National Health Committee
Section 11 advisory Committee responsible for
providing the Minister of Health with
recommendati...
Today …
Burning platforms - why we need to change!
•
•
•
•
•
•
•

Vote Health
GDP and GNP
Health, wellness and independenc...
Today …
Opportunities
• Evidence - data, information and knowledge
• Models of care
• Explicit prioritisation

Enablers
•
...
What are we trying to achieve?
• Safe, quality health, wellbeing and
independence outcomes for individual
patients and pop...
This has major implications for organising
health and long term care
•

Sustainability (e.g.
Systems evolved to manage acu...
Growth in core Crown health spending has
in core Crown health spending
Growth
has outstripped national income...
outstripp...
This has major implications for organising
Projected change in composition of
health and long term care
govt expenditure (...
Vote Health 12/13: NZ$14 billion
Primary
Health
Public Health

Maternity
Ministry

Education
Disability

DHBs
LEGATUM INSTITUTE | THE 2013 LEGATUM PROSPERITY INDEXTM
This Why is health care spending
has major implications for organising
health and long term care

increasing?

• Systems e...
Consider …
Our systems have developed to manage
acute life threatening conditions.
• Care is episodic and reactive
• Empha...
But the world has changed …
Increasing population of people with Long Term
Conditions (LTC)
• COPD, diabetes, CVD, dementi...
Trends in Age-Standardized Death Leading Causes Death in the United
e 1. Trends in Age-Standardized Death Rates for the Si...
This has major implications for organising
Long term care spending as % GDP, OECD, 2008
health and long term care
• System...
NHS
• 3.6m (21.9%) of ED attendances
require admission
• 37% increase in 10 years
• 65% are older (>65 years) - frail,
dem...
Just in case you think …
New Zealand

Australia
12 chronic conditions
accounted for 1.5m (21.8%)
of hospital separations
•...
The challenge
is to adapt the system to the
changing burden of disease in the
face of expanding technology
options and con...
This has major implications for organising
So what are the implications for
health and long term care

strategic policy?

...
NHC approach …
• Evidence based, assessment and
prioritisation of non-drug technologies with
a focus on models of care
• F...
NHC Programme Budget 12/13
Annual referral round
• Health Sector Forum
• 10 referrals
Figure 1: NHC Workflow Diagram

Source:
NHC Business Plan

2013/14

NHC Tiered Business Approach to Work Plans
Sector Engagement and Participation
Figure 2: NHC T...
Tier 1 Strategic Overview
Respiratory Disease in New Zealand
• $265m public casemix hospital discharges
• 10 disease state...
Appendix 2: Respiratory Disease Growth in terms of Mean Price for Publically Funded Hospital Casemix Events (inpatient or
...
Appendix 1: NMDS Summary Data for Publically Funded Hospital Casemix Events (inpatient or day patient) for 2011/12

Burden...
Burden of Respiratory Disease

DALY Breakdown by Percentage

Death Breakdown by Percentage

Source: NZBDS 2013
Incident Diseases: Efficiency Gains Required to Reach $5 million

2013 NHC Executive Analysis of 2011/12 NMDS
Tier 2 COPD: A Pathway to Prioritisation
• Inform Sector Working Group - develop an
evidence based end to end Model of Car...
Figure 2: COPD Hospitalisation Rates in the OECD

COPD benchmarking

Source: OECD Data 2011
NHC Programme Budget 12/13
Renal Sympathetic Nerve Ablation
Estimated prevalence of resistant hypertension
• Australia
n= 260,000
• New Zealand n= 97...
TAVI for Aortic Stenosis
Application; NHS 16-25 per million population?
Comparator; sAVRepl
Approximate costs index admiss...
So …
Success …
• Long run game - there are no simple
solutions or quick wins!
• The changes are complex, multifaceted and
need ...
Anne Kolbe, National Health Committee: The Changing Landscape Of Health Technology Assessment In New Zealand
Anne Kolbe, National Health Committee: The Changing Landscape Of Health Technology Assessment In New Zealand
Anne Kolbe, National Health Committee: The Changing Landscape Of Health Technology Assessment In New Zealand
Anne Kolbe, National Health Committee: The Changing Landscape Of Health Technology Assessment In New Zealand
Anne Kolbe, National Health Committee: The Changing Landscape Of Health Technology Assessment In New Zealand
Anne Kolbe, National Health Committee: The Changing Landscape Of Health Technology Assessment In New Zealand
Anne Kolbe, National Health Committee: The Changing Landscape Of Health Technology Assessment In New Zealand
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Anne Kolbe, National Health Committee: The Changing Landscape Of Health Technology Assessment In New Zealand

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Anne Kolbe, Chair, National Health Committee, NZ delivered this presentation at the 2013 Health Technology Assessment conference. The event is designed to stimulate innovation, understanding the benefits of health technologies and delivering a safe, effective and efficient health system for all. For more information, please visit the conference website: http://www.healthcareconferences.com.au/htaconference

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Anne Kolbe, National Health Committee: The Changing Landscape Of Health Technology Assessment In New Zealand

  1. 1. Creating a cost effective and sustainable health system using an evidence base Health Technology Assessment Conference Anne Kolbe ONZM, MBBS (Hons), FRACS, FRCSEng (Hon), FCSHK (Hon), FRCSEd (Hon), MAICD Chair, New Zealand National Health Committee
  2. 2. Declarations of Interest • Vocationally registered paediatric surgeon • Chair, National Health Committee • Director, Pharmaceutical Management Agency (PHARMAC) 2010 - 2013
  3. 3. National Health Committee Section 11 advisory Committee responsible for providing the Minister of Health with recommendations on: • Which technologies should be publicly funded in New Zealand • To what level and where technology should be provided • How new technology should be introduced and old technology removed
  4. 4. Today … Burning platforms - why we need to change! • • • • • • • Vote Health GDP and GNP Health, wellness and independence - prosperity Burden of disease Technology - goods and services Capital, back office and IT infrastructure Workforce
  5. 5. Today … Opportunities • Evidence - data, information and knowledge • Models of care • Explicit prioritisation Enablers • • • • Innovative macro level thinking Business / clinical partnership Values based relationships Leadership
  6. 6. What are we trying to achieve? • Safe, quality health, wellbeing and independence outcomes for individual patients and populations • Live within our means - value for money and affordability • Sustainability
  7. 7. This has major implications for organising health and long term care • Sustainability (e.g. Systems evolved to manage acute infectious), life-threatening conditions – care tended to be episodic, reactive, delivered by individual to provide Continuing professionals the range and – emphasis on hospitals & doctor-led care organised types of services (outcomes) currently around medical specialties – patients were seen as passive rather than available, or better, without incurring contributors to their own care excessive levels of taxes and /on LTCs or debt. • Even systems with strong emphasis suffer from variations in quality, weaknesses in coordination, unplanned hospital admissions Nicholas Mays, London School of Hygiene and Tropical Medicine, Affording Our Future Wellington, December 2012
  8. 8. Growth in core Crown health spending has in core Crown health spending Growth has outstripped national income... outstripped national income … Core Crown health expenditure per capita and GDP per capita (indexedreal growth Core Crown health expenditure per capita and GDP per capita indexed real growth) This has major implications for organising health and long term care Health: 412% % change since 1950 450% 400% • Systems 350% evolved to manage acute (e.g. infectious), life-threatening conditions 300% – care tended to be episodic, reactive, delivered by individual professionals GDP: 144% 200% – emphasis on hospitals & doctor-led care organised around medical specialties 150% 100% – patients were seen as passive rather than contributors to their own care 250% 50% 1950 1952 1954 1956 1958 1960 1962 1964 1966 1968 1970 1972 1974 1976 1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 • Even systems with strong emphasis on LTCs 0% suffer from variations in quality, weaknesses in coordination, unplanned hospital admissions Nicholas Mays, London School of Hygiene and Tropical Medicine, Affording Our Future Wellington, December 2012
  9. 9. This has major implications for organising Projected change in composition of health and long term care govt expenditure (excl. financing) • Systems evolved to manage acute (e.g. 2010 infectious), life-threatening conditions – care tended to be episodic, reactive, delivered by 21% individual professionals 2060 Health – emphasis on hospitals & doctor-led care organised Superannuation around medical specialties – patients were seen Education as passive rather than 31% contributors to theirOther care own Non-NZS emphasis on LTCs • Even systems with strongwelfare suffer from variations in quality, weaknesses in coordination, unplanned hospital admissions Nicholas Mays, London School of Hygiene and Tropical Medicine, Affording Our Future Wellington, December 2012
  10. 10. Vote Health 12/13: NZ$14 billion Primary Health Public Health Maternity Ministry Education Disability DHBs
  11. 11. LEGATUM INSTITUTE | THE 2013 LEGATUM PROSPERITY INDEXTM
  12. 12. This Why is health care spending has major implications for organising health and long term care increasing? • Systems evolved to manage acute (e.g. infectious), life-threatening Demographics - in part conditions – care tended to be episodic, reactive, delivered by Non demographics - may be as important! individual professionals – emphasis on hospitals & doctor-led care organised • Income growth -specialties expectations around medical • Technology - widening scope to than – patients were seen as passive rather treat contributors to their own care • Lower productivity growth than the rest of the • Even systems with strong emphasis on LTCs economy -variations in quality, weaknesses in suffer from health care is labour intensive coordination, unplanned hospital admissions Nicholas Mays, London School of Hygiene and Tropical Medicine, Affording Our Future Wellington, December 2012
  13. 13. Consider … Our systems have developed to manage acute life threatening conditions. • Care is episodic and reactive • Emphasis on hospitals and doctor lead care organised around medical specialties • Patients often seen as passive rather than active contributors to their own care
  14. 14. But the world has changed … Increasing population of people with Long Term Conditions (LTC) • COPD, diabetes, CVD, dementia and some cancers • Most of these people have >1 LTC • Many are over 65 years • LTC are a potent driver of ambulatory care sensitive admissions and costs
  15. 15. Trends in Age-Standardized Death Leading Causes Death in the United e 1. Trends in Age-Standardized Death Rates for the Six rates for theofSix leading Causes age-adjusted to the United States, 1970 1970-2002.1 Rates are of Death in the 2000 US standard population. – 2002. Jemal A, Ward E et al (2005). Trends in the Leading Causes of Death in the United States, 1970 - 2002.Journal of the American Medical Association 295 (10): 1255 - 59 Jemal, Ward, Hao, and Thun, 2005 method of coding causes of death from 1970 to 2002 changed twice – from ICD 8 to ICD 9 to ICD 10. Because of the
  16. 16. This has major implications for organising Long term care spending as % GDP, OECD, 2008 health and long term care • Systems evolved expenditure private LTC expenditure to manage acute (e.g. public LTC infectious), life-threatening conditions 4.0 • Even systems with strong emphasis on LTCs suffer from variations in quality, weaknesses in coordination, unplanned hospital admissions Nicholas Mays, London School of Hygiene and Tropical Medicine, Affording Our Future Wellington, December 2012 Netherlands Norway Finland Switzerland Denmark Belgium Iceland France Japan Canada OECD New Zealand Luxembourg Germany Austria Slovenia United States Australia Spain Poland Korea Hungary Slovak Republic Czech Republic – care tended to be episodic, reactive, delivered by individual professionals 1.4% 1.5% – emphasis on hospitals & doctor-led care organised around medical specialties – patients were seen as passive rather than contributors to their own care Portugal 3.5 3.0 2.5 2.0 1.5 1.0 0.5 0.0 Sweden % of GDP
  17. 17. NHS • 3.6m (21.9%) of ED attendances require admission • 37% increase in 10 years • 65% are older (>65 years) - frail, dementia, complex needs • Utilise 51,000 ABD (70% of total available ABD) • 33% fewer, general and acute beds • Ave LOS now increasing for patients >85 years Evidence of fractured care, breakdown in out of hours care, medical workforce crisis, capital and IT limitations RCP 2012
  18. 18. Just in case you think … New Zealand Australia 12 chronic conditions accounted for 1.5m (21.8%) of hospital separations • Stroke • COPD • CHD • Diabetes Average LOS 6 -10 days AIHW 2010-11 • • • • • • • • 21% increase in acute medical discharges (225,000) Chest Pain 3.6% GI 3.5% Respiratory Infections 3.5% Cellulitis 3.0% Circulatory Disorders 2.5% COPD 2.5% Abominal pain 2.5% Neonatal 2.8% NZ Ministry of Health 2012
  19. 19. The challenge is to adapt the system to the changing burden of disease in the face of expanding technology options and constrained resources
  20. 20. This has major implications for organising So what are the implications for health and long term care strategic policy? • • • • • Systems evolved to manage acute (e.g. infectious), life-threatening conditions Encourage active healthy populations - minimize – care tended to needs and costs be episodic, reactive, delivered by individual professionals Early identification of diseases – emphasis on hospitals & doctor-led care organised Quality, cost effective management of disease in around medical specialties – patients were health passive rather than the community - seen asand social sector contributors to their own care Ensure the workforce, IT infrastructure, capital •investment and funding streams are developed and Even systems with strong emphasis on LTCs suffer from variations in quality, weaknesses in aligned to enable the changing models of care coordination, unplanned hospital admissions Nicholas Mays, London School of Hygiene and Tropical Medicine, Affording Our Future Wellington, December 2012
  21. 21. NHC approach … • Evidence based, assessment and prioritisation of non-drug technologies with a focus on models of care • Four domains • • • • Clinical safety and effectiveness Societal and ethical Economic Feasibility of adoption • 11 decision making criteria • A4R framework
  22. 22. NHC Programme Budget 12/13
  23. 23. Annual referral round • Health Sector Forum • 10 referrals
  24. 24. Figure 1: NHC Workflow Diagram Source:
  25. 25. NHC Business Plan 2013/14 NHC Tiered Business Approach to Work Plans Sector Engagement and Participation Figure 2: NHC Tiered Approach for Prioritising Work Plans/Seeking Advice and Engaging with the Health Sector Source: NHC Executive
  26. 26. Tier 1 Strategic Overview Respiratory Disease in New Zealand • $265m public casemix hospital discharges • 10 disease states within respiratory disease • prevalence, incidence, health outcomes, health utilisation and cost Identify the disease state for Tier 2 assessment with the aim of improving health outcomes whilst maintaining or reducing costs through the prioritisation and application of the most cost effective new and existing health technologies across a model of care Source: NHC Respiratory Disease in New Zealand
  27. 27. Appendix 2: Respiratory Disease Growth in terms of Mean Price for Publically Funded Hospital Casemix Events (inpatient or day patient) from 2009/10 to 2011/12 Mean price ($k) 35 Decay (<0%) 30 Low growth (0<2%) Medium growth (2<4%) High growth (4-8%) Cystic fibrosis (Total=$6M Growth=0.4%) 25 20 Tuberculosis (Total=$2M Growth=-19.5%) 15 Lung cancer (Total=$13M Growth=-2.7%) 10 5 Lower tract infection (Total=$112M Growth=-0.9%) COPD (Total=$54M Growth=1.5%) Other (Total=$45M Growth=2.9%) Asthma (Total=$17M Growth=-5.7%) 0 0 5000 Source: 2013 NHC Executive Analysis of 2009/10–2011/2012 NMDS 10000 15000 Individuals (n) 20000 25000 30000
  28. 28. Appendix 1: NMDS Summary Data for Publically Funded Hospital Casemix Events (inpatient or day patient) for 2011/12 Burden of Respiratory Disease Total Price ($M) Mean Price ($k) Individuals (n) Mean growth (%) Discharges (n) 30 Day Acute Readmission (%) 2010 Mortality (n) 2010 Years of Life Lost (YLL) Time in Care (Years) Tuberculosis 2 14.1 150 -19.5 185 16.8 17 261 7 Obstructive Sleep Apnoea 3 4.5 721 0.3 736 0.8 11 328 4 ILD/Sarcoidosis 3 8.7 352 6.1 454 12.6 156 2,110 7 Pulmonary Artery Disease 4 3.3 1,273 -0.8 1,421 7.6 39 730 10 Bronchiectasis 5 7.3 682 4.5 1,065 17.4 94 1,560 16 Cystic Fibrosis 6 28.1 229 0.4 568 14.1 8 421 15 Lung Cancer 13 9.3 1,401 -2.7 1,908 15.3 1,622 29,828 27 Asthma 17 2.5 6,619 -5.7 8,403 9.6 57 1,625 34 Other Respiratory Disorders 45 4.4 10,190 2.9 11,089 6.1 82 878 68 COPD 54 7 7,716 1.5 11,619 17.9 1,588 20,121 134 Lower Resp Tract Infection /Influenza 112 4.7 24,092 -0.9 28,261 9.3 554 5,537 270 TOTAL 265 5.2 50,664 -0.3 65,709 10.6 4,228 63,397 592 Source:2013 NHC Executive analysis of 2010-2011/12 NMDS and 2010 National Mortality Collection
  29. 29. Burden of Respiratory Disease DALY Breakdown by Percentage Death Breakdown by Percentage Source: NZBDS 2013
  30. 30. Incident Diseases: Efficiency Gains Required to Reach $5 million 2013 NHC Executive Analysis of 2011/12 NMDS
  31. 31. Tier 2 COPD: A Pathway to Prioritisation • Inform Sector Working Group - develop an evidence based end to end Model of Care • Identify significant evidence gaps – HTA • Integrate innovation - HiP
  32. 32. Figure 2: COPD Hospitalisation Rates in the OECD COPD benchmarking Source: OECD Data 2011
  33. 33. NHC Programme Budget 12/13
  34. 34. Renal Sympathetic Nerve Ablation Estimated prevalence of resistant hypertension • Australia n= 260,000 • New Zealand n= 97,000 Costs • • Index admission A$11,000 Medical management A$1,200 “Back of the envelope” budget impact … • • Australia >A$3 billion New Zealand A$1 billion So where does this intervention fit in a model of care for refractory hypertension and what is the appropriate target population? Isler M et al. Lancet 2010; 376: 1903-9 Krum H. Hypertension 2011; 57: 911-7 HealthPACT 2013
  35. 35. TAVI for Aortic Stenosis Application; NHS 16-25 per million population? Comparator; sAVRepl Approximate costs index admission + 2years FU care • • sAVRepl A$25,000 TAVI A$63,000 Questions • • How to identify the population most able to benefit? Substitution or Addition financial methodology?
  36. 36. So …
  37. 37. Success … • Long run game - there are no simple solutions or quick wins! • The changes are complex, multifaceted and need to occur at all levels • “Big picture” strategy - involves action • Evaluation, evaluation, evaluation … and constant tweaking! • Consistent and persistent national leadership
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