Health Technology Assessment Panel
On Tuesday, June 13, 2017, the Canadian Association for Healthcare Reimbursement (CAHR) held the Market Access 201 conference in Toronto. The theme for this conference was Parallel or Intersecting Paths, the Future of Public and Private Reimbursement in Canada which consisted of five fascinating panels focusing on key topics of interest to the Canadian pharmaceutical stakeholders. Over the coming weeks, MORSE will be releasing summaries for each panel to share key learnings from this conference. This issue will focus on the HTA panel discussion.
Session Topic: Health Technology Assessment
Description: This panel will explore current developments and the evolving role of health technology assessment for both public and private drug plans. We will discuss CADTH’s increasingly important role with the pCPA in terms of therapeutic reviews, requests for advice and price reduction analyses, as well as the potential for CADTH to develop closer alignment with other key stakeholders like Health Canada and INESSS. With respect to private payers, we will investigate how private payers are approaching and utilizing HTA in an environment of increased scrutiny of specialty drug products.
Speakers:
Helen Stevenson, BCom, MSM, ICD.D, Founder and CEO, Reformulary Group Inc.
Trevor Richter, Director, Common Drug Review and Optimal Use, CADTH
Jeffrey Hoch, PhD, Professor, Department of Public Health Sciences, Associate Director, Center for Healthcare Policy and Research UC Davis
Dr. Chander M. Sehgal, MBA, MD, Executive Director, Access & Reimbursement Policy, Innovative Medicines Canada (MODERATOR)
Summary:
Dr. Chander M. Sehgal, MBA, MD, Executive Director, Access & Reimbursement Policy, Innovative Medicines Canada
HTA is a relatively young discipline or science. It’s not one science. It’s many disciplines that are brought together. It is evolving at a rapid pace compared to anything else in the healthcare decision making sector. There are questions around comparative effectiveness and incorporating real world evidence. We are focusing exclusively on drugs today. Health economics and its application continue to evolve. Some HTA organizations rely heavily on cost-effectiveness and cost utility analyses. Patient inputs are being used more frequently. The purpose of HTA is to inform downstream funding decisions and help the payers manage uncertainty. So the first question we have for each panelist today is how is HTA evolving and what problems are you being asked to solve?
Jeffrey Hoch, PhD, Professor, Department of Public Health Sciences, Associate Director, Center for Healthcare Policy and Research UC Davis
The experiences I have had in the private market have been in studying disability programs. I would like to identify some areas that distinguish research for private payers:
- Cost perspective: Often private payers are on the hook for different things from public payers. For example; with hospitals, the public payer covers a “basic” room but the private payer might have to pay for a “better” type of room.
- Outcomes: In healthcare, the QALY makes a lot of sense, but as a private payer maybe what you care about is how well does that worker perform. The concept of presenteeism is the workplaces’ adaptation of the QALY.
- Different populations: Working people may be younger and more employed than older populations. Answers may be different for different populations (the cost-effectiveness of an innovation may vary by age).
- Pace: There is a need for speed among private payers.
Helen Stevenson, BCom, MSM, ICD.D, Founder and CEO, Reformulary Group Inc.
Having spent 5 years in the public sector, I believe the public plans do a great job with HTAs. The private sector is very different: six years ago, an estimated 92% of the plans had open formularies and every drug got added.
Only a very few groups in the private sector do HTAs; we certainly do. HTA is not about cost containment, it is about sustainability. The vision I had was to bring the rigour of HTAs into the private sector, and build a formulary on that basis (aka The Reformulary).
The private sector is also unique in its beneficiaries: typically active populations, whereby payers are also paying for disability, life insurance etc. To that extent, disability is a significant cost for employers, and drugs that can prevent or delay members from going on long-term disability may be hugely valuable to members and to the plan.
Private sector plans still have a long way to go, as an estimated 92% of plans with open formularies has been reduced to 85%. Most private plans now have generic substitution and prior authorization.
Economic value is important but I do not believe that the employers have factored it in very much or even clinical value. It is hugely important from the perspective of the value of people returning to work. Private payers will pay for a more expensive drug if it brings real value to working populations.
Plans are concerned about sustainability. Some employers are cutting benefits or capping what they pay. But, a $1000 cap may not even cover diabetes medications. Some plans are cutting speciality medications and hoping the government will pick everyone up.
Trevor Richter, Director, Common Drug Review and Optimal Use, CADTH
As Director I’ve seen dramatic shifts in the environment. We have three new best friends: Health Canada, INESSS and pCPA. The work in the short to medium term will be focused on these partnerships. Perhaps in the future we can add in private payers.
Comments from the Minister have forced us to work quickly. From Health Canada we need enhanced engagement for CADTH, where can we make an impact and deliver for the health minister? We are working on establishing effective communication between Health Canada and ourselves. The key goal for this work is addressing and shortening the time to listing.
For pCPA we are trying to improve integration with the CADTH processes, and learning where new processes need to be put in place. From CADTH’s perspective we are deriving where we can create real value to the pCPA and not creating any delay in the process.
We are learning about ways to provide different types of support outside of the usual recommendation. Being agile in the space and move the files forward.
INESSS is now a part of pCPA and we have found we are becoming more engaged with them. They are evolving their own process and jointly involve both bodies in the environment that is demanding broad engagement and efficiency.
QUESTIONS
On May 16, 2017, the Minister of Health delivered a speech and part of that was revisiting and reviewing drug review cycles and focus on the relationship between Health Canada and CADTH reviews. How is CADTH defining efficiency such as time to listing? What is the objective of enhanced engagement?
TR: So I think this is work in progress and started fairly recently. Time to listing is not a simple thing to fix. I think right now we are focusing on information sharing with Health Canada. It is establishing mechanisms to share information the regulator has with CADTH and vice versa. Being privy to information the regulator has as soon as possible will create efficiencies. Manufacturers will be a crucial part of that agreement as well. How is Health Canada looking at prioritization vs. HTA? There is a difference in the way the payers define priority vs. the regulatory and these are not concordant.
On the private side, what information is most important to them from an HTA perspective? There has been discussion that the large carriers are looking at public information, is it required for them and is it being used?
HS: The majority do not engage in HTA processes. We are moving to areas of sustainability. There are more resources available publicly so it’s a matter of how they can incorporate that. They have not been deeply involved on the decisions of what drugs.
There are cost implications as well, the CDR will say do not list without implementing x,y,z which is not relevant to private plans since they cannot negotiate. They still look to CADTH and NICE but the plan has to be equipped to incorporate it into their process.
What about the timeline to decision making?
HS: We have highly qualified and experienced people, we can turn these around in 3 to 6 months but understand why the public side takes longer. It is a level of rigour as well. With the majority, again they really don’t have the same level of rigour, so the decisions are more simplified. The HTA is more focused on specialty drugs. They are not set up to do detailed review.
The private plans mostly cater to populations in active work force and productivity gains are an important consideration. From an economic analysis perspective, should they be different?
JH: HTA is smart shopping, and private payers have different things that matter to them. Private payers will likely care more about productivity than public payers. The evidence needs to consider value where the payer finds it. In this case, we need a tool that finds the value for the private payer.
With regards to drugs for rare disease, CADTH is moving in some directions and it is a spot that does not fit neatly in a health economic analyses. Where may it help and where it may not help? It may never be cost-effective.
JH: HTA creates spaces where you can put things that have value to you. If you only look at efficiency, the most efficient investments producing the most health for the most people probably do not include those for DRD. However, we all know, there are other things that matter in addition to efficiency. For example, at a company there may be great value in helping someone who is valued by the company. You can signal that in the way you invest.
HS: Jeff is spot on. It’s more about guiding clinical appropriateness. Who will benefit the most? Some of them may do more harm than good. It is more about ensuring its just those people who will benefit the most.
TR: The HTA perspective is challenging and the CADTH position has been challenging in the orphan drug space due to the lack of clear guidance from the regulator. Economic assessments are a challenge and our perspective is likely not different on the surface. Moved toward affordability. They cannot be rejected based on unattractive ICERs.
In the final panel at the CADTH symposium with the EMA director of scientific affairs he identified that there is a need to continue division between regulator and HTA. I view the regulator as a form of HTA and then goes down to the next level. Having spent a lot of time in the US how would you react to that to continue keeping that separation?
JH: I like the idea of CADTH and Health Canada talking more. They behave differently because they are required to answer different questions. Are there efficiencies in answering separate questions together?
TR: Ultimately, I think if we think about improving efficiency in the blue sky world you would have joint assessments. That’s so far down the line. At CADTH we are dealing with convergence and it is slow. You would need merging of the questions for that to make sense.
Final Thoughts
TR: There will be a number of changes over the next 6-9 months to the program. Concrete changes.
HS: There are a lot of organizations involved, how can we start to converge some of these roles?
JH: The three points I wanted to remind you of
- We might need different methods;
- Even with the same methods with different populations there may be different answers;
- Speed is important.
MORSE thanks our Reimbursement Strategist, Avery Hughes, for diligently preparing these summary notes during the conference. This summary is not an official transcript of the presentations/ discussions – as such, it may contain some errors/omissions/misinterpretations. Please contact the CADTH, IMC, Reformulary Group or Dr. Jeffrey Hoch if you would like additional information or clarification on this topic.
Summary of Health Technology Assessment Panel discussions from the June 13, 2017 CAHR 201 conference. Share on X
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