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Balancing needs and resources in medicines delivery


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Presentation delivered by Mr Shaun Flanagan, Corporate Pharmaceutical Unit, Health Service Executive at the Irish Pharmaceutical Healthcare Association Annual Meeting 2009.

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Balancing needs and resources in medicines delivery

  1. 1. Balancing needs and resources in medicines delivery The Challenge NOW and into the future Shaun Flanagan, Corporate Pharmaceutical Unit
  2. 2. Medicine Supply: Core Principles 2006 <ul><li>Public access to innovative and other medicines through reimbursement based on: </li></ul><ul><ul><li>affordability </li></ul></ul><ul><ul><li>sustainability </li></ul></ul><ul><ul><li>continuity and security of supply </li></ul></ul><ul><ul><li>value for money </li></ul></ul><ul><li>Strategic view / available resources </li></ul>
  3. 3. Making Room for Innovation: Finding the Balance 2006 <ul><li>IPHA agreement </li></ul><ul><li>Pricing </li></ul><ul><ul><li>new products: expanded basket </li></ul></ul><ul><ul><li>reviews: early launch </li></ul></ul><ul><ul><li>patent expiry: price reductions </li></ul></ul><ul><li>Health technology assessment (HTA) </li></ul><ul><ul><li>clinical innovation, benefits </li></ul></ul><ul><ul><li>new or existing therapies </li></ul></ul><ul><ul><li>budget impact </li></ul></ul>
  4. 4. 2006 Agreement <ul><li>€ 250M reduction in the rate of escalation over 4 years (Clause 6) </li></ul><ul><li>Not a net reduction in costs to the state </li></ul><ul><li>All reductions re-invested by the state in the provision of medicines </li></ul>
  5. 5. High Tech arrangements
  6. 6. Where are we now? Where are we likely to go?
  7. 7. 2009 Economic Reality <ul><li>Department of Finance Monthly Economic Bulletin November 2009 </li></ul>
  8. 8. Projecting the Impact of Demographic Change on the Demand for and Delivery of Healthcare in Ireland <ul><li>Layte, Richard (ed.) </li></ul><ul><li>Barry, Michael (TCD) </li></ul><ul><li>Bennett, Kathleen (TCD) </li></ul><ul><li>Brick, Aoife </li></ul><ul><li>Morgenroth, Edgar </li></ul><ul><li>Normand, Charles (TCD) </li></ul><ul><li>O'Reilly, Jacqueline </li></ul><ul><li>Thomas, Stephen (TCD) </li></ul><ul><li>Tilson, Leslie (TCD) </li></ul><ul><li>Wiley, Miriam M </li></ul><ul><li>Wren, Maev-Ann (TCD) </li></ul>
  9. 9. 2006 -> 2020 (ITEMS 2021) <ul><li>Current use model </li></ul><ul><ul><li>Items increase from 54M -> 75M </li></ul></ul><ul><ul><li>Ingredient costs €1.1Bn -> €1.5Bn </li></ul></ul><ul><li>Projected use model </li></ul><ul><ul><li>Items increase from 54M -> 110M </li></ul></ul><ul><ul><li>Ingredient costs €1.1Bn -> €2.4Bn </li></ul></ul>
  10. 10. Limitations of Predictions <ul><ul><li>Assumptions made </li></ul></ul><ul><ul><li>Recent changes to schemes not included </li></ul></ul><ul><ul><ul><li>Changes to eligibility in over 70 year olds </li></ul></ul></ul><ul><ul><ul><li>January 2009 - 15% reduction post-patent </li></ul></ul></ul><ul><ul><ul><li>Any future changes to IPHA / APMI </li></ul></ul></ul><ul><ul><li>Only public spending </li></ul></ul><ul><ul><li>New treatments, changing expectations, changing disease epidemiology not possible to predict </li></ul></ul><ul><ul><ul><li>High Tech Arrangements not included </li></ul></ul></ul>
  11. 11. Health system - Challenges <ul><li>In an overall healthcare context the need to deliver better care for less money </li></ul><ul><li>How can access to new and innovative medicines be provided for in the context of an aging population and forecasted declining health expenditure? </li></ul>
  12. 12. Clinical Care & Quality <ul><li>Deliver better care for less money </li></ul><ul><li>Chronic disease management programmes including </li></ul><ul><ul><li>Asthma </li></ul></ul><ul><ul><li>Diabetes </li></ul></ul><ul><ul><li>Cardiovascular diseases </li></ul></ul><ul><li>Clinician led </li></ul><ul><li>Multidisciplinary support </li></ul>
  13. 13. Clinical Care & Quality <ul><li>Guidelines </li></ul><ul><li>Structured Care pathways </li></ul><ul><li>Right Healthcare professional @ right time </li></ul><ul><li>Early intervention </li></ul><ul><li>Target resources in these areas </li></ul><ul><li>Reduce long term complications and improve population health </li></ul><ul><li>No overall increase in investment </li></ul><ul><li>Pharma programme </li></ul>
  14. 14. Medicine Supply: Core Principles 2010 <ul><li>Access to innovative and other medicines through reimbursement based on: </li></ul><ul><ul><li>affordability </li></ul></ul><ul><ul><li>sustainability </li></ul></ul><ul><ul><li>continuity and security of supply </li></ul></ul><ul><ul><li>value for money </li></ul></ul><ul><li>Strategic view / Economic reality </li></ul>
  15. 15. Investment in Innovative medicines <ul><li>Ensure that any medicine to be reimbursed is cost effective </li></ul><ul><ul><li>Health technology assessment </li></ul></ul><ul><ul><li>Cost effectiveness and price </li></ul></ul><ul><ul><li>No additional funding is expected </li></ul></ul><ul><ul><li>Difficult choices ahead </li></ul></ul>
  16. 17. Investment in Innovative medicines <ul><li>Balance between rapid access to medicines and planned use of scarce resources </li></ul><ul><li>Meeting very short timescales specified under current agreements is and will be challenging </li></ul><ul><li>May not always be conducive to strategic decision making </li></ul>
  17. 18. Medicines for Orphan Diseases <ul><li>Should (can) the state pay a premium for orphan medicines particularly those which would not satisfy standard cost effectiveness requirements? </li></ul><ul><li>Opportunity costs versus unmet clinical needs </li></ul><ul><li>Often a bridge to further therapeutic advances </li></ul><ul><li>What is a reasonable premium? </li></ul>
  18. 19. Core Principles <ul><li>Generate financial headroom to support the predicted growing pharmaceutical needs of an aging population </li></ul><ul><li>Allocative decisions must be made in the context of a full understanding of opportunity costs </li></ul><ul><li>Increased role of experts in informing decisions about investment in medicines </li></ul>
  19. 20. Financial Headroom <ul><li>Continue the movement of prices towards the EU average </li></ul><ul><li>Maximise the potential of generic market to provide headroom for innovative medicines </li></ul><ul><li>Identify medicines which are not cost effective (Health technology assessment) </li></ul>
  20. 21. Financial Headroom <ul><li>Review all supply chain costs and methods of delivery to identify inefficiencies </li></ul><ul><li>Improve Adherence </li></ul><ul><li>Improve Efficacy in use </li></ul>
  21. 22. Financial Headroom – efficacy in use <ul><li>Modern medicines deliver significant benefits to individuals and society </li></ul><ul><li>However complications do arise and some of these are avoidable </li></ul><ul><li>Priority of the new directorate and DOHC to address patient safety issues </li></ul>
  22. 23. Adverse drug reactions (ADR) as cause of admission to hospital <ul><li>BMJ 2004 Vol 329; 15 19 </li></ul><ul><li>Pirmohomad et al. BMJ 2004 Vol 329; 15 19 </li></ul><ul><li>UK Study </li></ul><ul><li>ADR caused 1225 (6.5%) admissions. </li></ul><ul><li>107 “definitely avoidable” </li></ul><ul><li>773 “possibly avoidable,” </li></ul><ul><li>880 might have been avoidable (4.7%) </li></ul><ul><li>23 patients died (0.15%) </li></ul>
  23. 24. TORCH: (NEJM 356;8 Feb 22 2007) <ul><li>A randomised, double-blind trial comparing </li></ul><ul><ul><li>combination therapy with a long acting beta agonist (LABA) and inhaled corticosteroids (ICS) </li></ul></ul><ul><ul><li>LABA alone </li></ul></ul><ul><ul><li>ICS alone </li></ul></ul><ul><ul><li>Placebo </li></ul></ul><ul><li>Patients with Chronic Obstructive Pulmonary Disease (COPD) followed over 3 years </li></ul>
  24. 25. TORCH: ( number, NCT00268216.) <ul><li>6112 patients, 42 countries, 444 centres </li></ul><ul><li>Overall 875 (14.3%) of patients died within the 3 years </li></ul><ul><li>All-cause mortality rates </li></ul><ul><ul><li>12.6% Combo group </li></ul></ul><ul><ul><li>13.5% LABA alone </li></ul></ul><ul><ul><li>16% ICS alone </li></ul></ul><ul><ul><li>15.2% Placebo </li></ul></ul><ul><li>Reduced exacerbations, improved health status and spirometric values </li></ul>
  25. 26. TORCH: POST HOC REVIEW OF ADHERENCE DATA <ul><li>Adherence to inhaled therapy, mortality and hospital admission in COPD </li></ul><ul><li>Post hoc review of TORCH data </li></ul><ul><li>Good aherence defined as > 80% use of study medication </li></ul><ul><li>Poor adherence defined as < 80% </li></ul><ul><li>Vestbo et al Thorax 2009;64:939-943 </li></ul>
  26. 27. Vestbo et al Thorax 2009;64:939-943
  27. 28. BMJ 2009;339:b2803
  28. 29. Summary <ul><li>Innovative medicines important in improving health outcomes </li></ul><ul><li>Demonstration of cost effectiveness is required </li></ul><ul><li>Financial constraints require that we deliver better care at a lower cost </li></ul><ul><li>Optimisation of medicines use can help fund future healthcare needs (and access to new innovative medicines) </li></ul>
  29. 30. Contact Details <ul><li>Corporate Pharmaceutical Unit, </li></ul><ul><li>Dr. Steevens' Hospital, Dublin 8. </li></ul><ul><li>Telephone: 01-6352672 </li></ul><ul><li>Email: [email_address] </li></ul><ul><li> </li></ul><ul><li>Thank you </li></ul>