HTA for Health System Sustainability: Opportunities and Challenges

John Embil, Denise Dunton, Don Juzwishin, Arminee Kazanjian, Petr Kresta

April 4, 2011CADTH Exchange WorkshopVancouver, British Columbia

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Objectives

• Background• The challenges • Alberta’s approach

to sustainability• HTA necessary but

not sufficient• Future

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Background• 3.5 million people• 13 former health jurisdictions• 90,000 staff• 9,000 leaders• 7,400 physicians• Macro – AACHT • Mezzo – AHS• Micro – Clinical settings with

patients & citizens

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The current state is notsustainable

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Cost of ED departments (adjusted for case mix) vary most in the Regional Hospitals

And Metropolitan – by up to 75% in some cases.

Cost of inpatient care (adjusted for case mix) varies by 24% in Tertiary and Regional and

13% in Metro

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39.6

22.9

31.9

49.3

98.2

105.2

0

20

40

60

80

100

120

Primary Care Day Surgery End of Life QI ALC ELOS (flow)

No.

of B

eds

Avo

ided

Avoidable Beds Opportunity Index

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Compared to other provinces, Alberta

Spends more per head

Uses more health services

(and those health services cost more)

But doesn’t get quicker access

Or appreciably better (population) outcomes

P rince Edward Is land(79.9, 2,184)

C anada(80.8, 2,464) Ontario

(81.1, 2,473)

B rit ish C o lumbia(81.4, 2,444)

Quebec(80.9, 2,202)

Alberta(80.5, 3,011)

N ew B runswick(80.1, 2,452)

N o va Sco t ia(79.6, 2,387)

Saskatchewan(79.4, 2,381)

M anito ba(79.3, 2,604)

N ewfo undland(78.2, 2,757)

1.8

2.0

2.2

2.4

2.6

2.8

3.0

3.2

78 79 80 81 82 83

Total Life Expectancy 1 vs. Constant (2002) 2 Provincial Health Expenditure 3

per Adjusted Capita 4, for 2006

Most provinces have experienced 8 to 10% growth in health spend each year,

Almost 50% of public expenditure is on health

Best performing

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Attributes of high performing

system

Information continuity

Care co-ordination and transitions

Team work for high value care

Continuous innovation

Easy access to appropriate care

System accountability

Commonwealth Commission on high performing

health systems 2008

OECD – value for money in health spending 2010

1. Evidence based medicine

and HTA

2. Incentives and pay for

performance

3. Co-ordinated care

4. Pharmaceutical pricing

5. ICT driven productivity

Right Care, Right Time, Right Place, Right Provider

Effective, accessible, equitable, efficient

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in almost half of OECD countries 50% or more of the population is

overweight

WHO estimates 60% of deaths world wide due to Chronic Disease,

86% in Europe

health inequalities that could be avoided by reasonable means are unfair.

Putting them right is a matter of social justice [Marmot – WHO]

Cross cutting strategies – making health improvement,

inequalities a responsibility of all social ministries

Early diagnosis and intervention, evidence based prevention

IS HTA prepared to help identify opportunities?

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Tipping point

Consensus for change

Structures and opportunities

Confluence of conditions…

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Premiers Vision

To develop the best performing publicly funded health care system in Canada

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Minister Zwozdesky’s Mandate Letter

Develop policy and accountability mechanisms to ensure AHS and other providers deliver improved health system quality, accessibility and sustainability for publicly funded health services.

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Explicit performance improvements

• How can HTA support clinical networks to achieve improvements

• http://www.albertahealthservices.ca/3201.asp

• Proactive stance

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Alberta’s goals

• One health care system for all Albertans• AHW and AHS must work as ONE• Single Communication Strategy• One IT/IM Plan• One Performance Management System• One Health Care Strategic Plan/Business Plan• One Health Care Action Plan

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Build on our strengths

• Single Health Board/Authority

• Five-year funding for AHS

• Five-year capital plan for health facilities

• Knowledgeable staff• GoA Full Support

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Strengthen our foundation

• Improving our communication• Clarify roles and responsibilities• Improving coordination and collaboration• Improve data sharing• Coordinated plans• Strategic/business/action• Support staff development and participation

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TIPS Transformation Improvement Projects

• TIP #1 Building a Primary Care Foundation• TIP #2 Improving access and reducing wait times• Tip #3 Choice and Quality for Seniors• Tip #4 Enabling our People to Achieve Excellence in

Providing Health Services• Tip #5 Enabling One Health System

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Clinical networks

To engage clinicians and patients in decision-making about clinical services planning and implementation, clinical practice improvement and quality and safety enhancements to ultimately improve patient care and services provided through AHS. Clinical Networks will foster greater partnership among clinicians, enhance the patient’s experience, enhance communication, increase collaboration, and enable shared accountability between clinicians and the organization for the quality and safety of the health care services we provide.

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Cer

tain

ty o

f Evi

denc

e

Effectiveness

Evidence certainEffective

Uncertain evidenceNot effective

Evidence certainNot effective

Uncertain evidence Effective

Promising technology

Ineffective technology

Technology to be adopted

2. Reassessment

1. Assessment

& Appraisal

4. Innovation

3. Access with Evidence Development

5. Education & Dissemination

OUTCOMES

Cer

tain

ty o

f Evi

denc

e

Effectiveness

Evidence certainEffective

Uncertain evidenceNot effective

Evidence certainNot effective

Uncertain evidence Effective

Promising technology

Ineffective technology

Technology to be adopted

2. Reassessment

1. Assessment

& Appraisal

4. Innovation

3. Access with Evidence Development

5. Education & Dissemination

OUTCOMES

Relationships among Levels of Effectiveness, Certainty and HTAI Programs

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Program elements

HTAI PROGRAM

AHS SERVICE

Asse

ssm

ent &

Appr

aisa

l

Rea

sses

smen

t

Acce

ss w

ith E

vide

nce

Dev

elop

men

t (A

ED)

Inno

vatio

n

diseaseprevention

health promotion

screening diagnosis intervention continuing care

palliativepublic health

CDMrehabilitation

Kno

wle

dge

Man

agem

ent &

Tran

slat

ion

Health Technology Assessment & Innovation Departmen t at Alberta Health Services

HTAI PROGRAM

AHS SERVICE

Asse

ssm

ent &

Appr

aisa

l

Asse

ssm

ent &

Appr

aisa

l

Rea

sses

smen

t

Acce

ss w

ith E

vide

nce

Dev

elop

men

t (A

ED)

Acce

ss w

ith E

vide

nce

Dev

elop

men

t (A

ED)

Inno

vatio

n

Inno

vatio

n

diseaseprevention

health promotion

screening diagnosis intervention continuing care

palliativepublic health

CDMrehabilitation

diseaseprevention

health promotion

screening diagnosis intervention continuing care

palliativepublic health

CDMrehabilitation

Kno

wle

dge

Man

agem

ent &

Tran

slat

ion

Health Technology Assessment & Innovation Departmen t at Alberta Health Services

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Spread of innovation in service organizations

“Help it happen”

“Let it happen”

“Make it Happen”

Unpredictable, unprogrammed,

uncertain, emergent, adaptive, self-organizing

Negotiated, influenced,

enabled

Scientific, orderly, planned, regulated,

programmed, systems “properly managed”

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How will HTA help …

• Macro – AHW – AACHT confluence and collaboration• Mezzo – AHS – HTAI • Micro – “bottom up” approach…”and by the way”• Facilitate and stimulate innovation• Support linkage and exchange with HTA producers• Cross cutting structures and processes to re-engineer• What is the ROI from HTA?

– For details http://www.albertahealthservices.ca/4122.asp

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Summary

• Challenges are immense but the opportunity for HTA and Innovation to contribute is great

• Commitment in governance is explicit• LEADS initiative involves everybody (CCHL)

• Lead self, engage others, achieve results, develop coalitions, systems transformation

• HTA is necessary but not sufficient• Clinical networks established work from “bottom up” and “top down”• Performance indictors report and monitor • Knowledge management and translation is the opportunity

unexploited

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