Value for money of Health Technology Assessment
Health Technology Assessment (HTA), despite the many definitions in use, has become almost synonymous with value for money (VfM). But just what is the value for money of HTA itself?
HTA and VfM
HTA has, at its heart, consideration of value; just what is the value of the technology under scrutiny? Will it add years of life? Will it improve quality of life? Both? And although HTA does not always include cost, it often does. This prompts the question of whether the value of a technology is worth it in terms of both the price tag and also the cost impact of its use, such as additional costs for diagnostic tests that might be needed, or cost savings, such as fewer hospital appointments. Those who stay true to economic principles will also consider not just the cost and any savings generated, but also the cost compared to what else precious health care pounds would be spent on.
But let’s not forget that doing a HTA is itself a cost. What is the cost of doing HTA?
The cost of doing HTA
The cost of HTA isn’t easy to figure out. In part that’s because there are quite a few components reflecting the idiosyncrasies of just how a country, region or even a hospital decide how to do it. But there are some common elements:
• The cost of the HTA agencies themselves or the salaries of those individuals who do the HTA. This also reflects the effort involved. Rapid or ‘mini’ HTA’s are an option – although I worry, given some anecdotes suggesting that such rapid HTAs might only take a day, that this amounts to little more than a Google search and a review of the Executive Summaries of other agencies’ HTA reports.
• Company participation. Many systems will include a company submission to support the HTA. That submission will be shaped by what the company has available already, often drawing on what was needed to satisfy regulators, but also what is set out as requirements by the HTA agency itself. The cost is borne by the company, so it’s hard to know what it is, but, given the thriving industry in consultancies, academics and others who offer their services to help companies, you can bet it’s not cheap. The submission will also only be part of the cost; add in time for the company to attend HTA-related meetings, clarify any questions about the submission and so on, and you can see it can be quite an undertaking.
• Other groups’ participation. Like companies, patient groups or individual patients can often, but not always, be allowed to make a submission. The cost here will probably be small, especially compared to what companies spend and the time they put in, but still it might be a high cost to the individual person in terms of time to fill in a template and/or attend to share their perspective. Similarly, clinicians, Royal Colleges and any other party involved will incur some costs in participation too.
• Academic review. Whilst not universal, some HTA agencies will have academics who play a role in scrutinising the company submission as well as perhaps doing their own analysis and hence there is a cost for such a review.
Who pays for HTA anyway?
In publicly-funded systems, tax is often used to pay for HTA agencies. For companies, costs are a part of doing business and will probably, in some way shape or form, feature in prices (although it’s got to be a teeny tiny part in the grand scheme of things).
Plans to charge industry for the Common Drug Review (CDR) process in Canada back in May 2014 prompted some reflection not only on the cost of HTA but also about who should pay. Clearly companies have an interest in getting a ringing endorsement of their product, or at least avoiding an outright rejection, but equally it’s increasingly an additional cost of bringing a product to market on top of all the other costs; it’s no mean feat to bring a new product to market, and it isn’t cheap.
The fee for HTA might be small, but it’s just one more cost on top of the millions or billions (depending whose estimates you believe) of getting a product prescribed to real life patients. Patients, clinicians, payers and governments are all, to a lesser or greater degree, beneficiaries too, so should industry pay for it all?
The cost of not doing HTA
If you stopped doing HTA right now, there would be a clear cost saving. But the tricky thing is that not doing HTA could mean bearing the hidden costs of making poorer decisions about where to spend money on health services and treatments. For example, spending on a technology that is simply no good is wasteful; more health improvement could have been generated by doing something else in the health care system. Equally, not spending on a technology that is both value for money and could even generate net cost savings, would be wasteful too.
The challenge also lies in ensuring that HTA is done well, and knowing when the results of HTA are ‘right’ since, in practice, whether or not you support a positive, negative or something-in-between recommendation, often seems to depend on your perspective.
What is probably worse is when a high quality HTA is done, but ignored, and all that time and effort amounts to nothing. That means taking a wider perspective; it’s not just a high quality, proportionate HTA approach that counts, but also that results are acted on. This, in turn, introduces a host of issues around how to incentivise often diverse, fragmented health care systems to take note of HTA recommendations.
Should the cost of doing HTA be more explicit?
With austerity still all around us, should the cost of doing HTA be made much clearer? It’s actually hard to find much that quantifies the cost of doing an appraisal. Research consultants ECORYS made an attempt when they were looking at the implications of European cooperation on HTA and they estimated that, in 2013, it cost €80,000 to €120,000 for a full HTA and just €30,000 for a rapid HTA. CDR now comes with a CAN$72,000 fee, and fees for PBAC can be as high as AUS$128,056.
A rough estimate for National Institute for Health and Care Excellence (NICE) Technology Appraisals (TAs) is £300,000, on average, based on the £9.7 million provided to the Centre for Technology Evaluation in 2013/14 (which does the TA work) and the 32 TAs published over that same financial year. With overheads, it will be more, as that price tag is just for NICE in-house work. Plus, with the time taken for TAs, and the differences in complexity, there will probably be big variations in costs for some TAs versus others.
Making the cost of HTA itself more explicit could have some positive impacts. It could help to focus minds on the duplication that can occur, which is part of the underlying rationale behind efforts to collaborate, such as the work being conducted by the EUnetHTA in Europe.
It may also help to identify more proportionate HTA approaches. So, would a light adaptation, accounting for local context and dealing with generalisation and transferability explicitly, do? This is part of the debate around creating a ‘pragmatic decision-making framework’ in parts of central and Eastern Europe for example.
Without a doubt, though, HTA is here to stay and making sure that it is, itself, value for money is a worthwhile cause.
About the author:
Leela Barham is an independent health economist and policy expert who has worked with all stakeholders across the health care system, both in the UK and internationally. Leela works on a variety of issues: from the health and wellbeing of NHS staff to pricing and reimbursement of medicines and policies such as the Cancer Drugs Fund and Patient Access Schemes. Find out more here and you can contact Leela on firstname.lastname@example.org
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