NATIONAL HEALTH COMMITTEE PETER GUTHRIE AND ANNE KOLBE NATIONAL HEALTH COMMITTEE 2015.
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Transcript of NATIONAL HEALTH COMMITTEE PETER GUTHRIE AND ANNE KOLBE NATIONAL HEALTH COMMITTEE 2015.
NATIONAL H
EALTH
COMMITTEE
PE
TE
R G
UT
HR
I E A
ND
AN
NE
KO
L BE
N AT I O N A L H E A LT H C O M M I T T E E 2 0 1 5
DISCLOSURE INFORMATION Peter Guthrie BA LLB
General Manager National Health Committee
Anne Kolbe ONZM, MBBS (Hons), FRACS, FRCSEng (Hon), FCSHK (Hon), FRCSEd (Hon), MAICD
Chair National Health CommitteePaediatric SurgeonAdjunct Associate Professor, University of AucklandMember, HealthPACTMember, Hospital Advisory Committee, Auckland District Health BoardMember, Risk and Audit Committee, Whanganui District Health BoardCo-chair, Policy Working Group International Global Leaders in GenomicsPrevious: Director, Pharmaceutical Management AgencyPrevious: President Royal Australasian College of SurgeonsChair, Review South Island Neurosurgery, 2010
N AT I O N A L H E A LT H C O M M I T T E E 2 0 1 5
N AT I O N A L H E A LT H C O M M I T T E E 2 0 1 5
Mirror, Mirror on the Wall, The Commonwealth Fund, June 2014
Source: OECD Health Data, 2012N AT I O N A L H E A LT H C O M M I T T E E
2 0 1 5
GROWTH IN CORE CROWN HEALTH SPENDING HAS OUTSTRIPPED NATIONAL INCOME …
Core Crown health expenditure per capita and GDP per capita indexed real growth
Nicholas Mays, London School of Hygiene and Tropical Medicine Affording Our Future, Wellington, December 2012
N AT I O N A L H E A LT H C O M M I T T E E 2 0 1 5
Nicholas Mays, London School of Hygiene and Tropical MedicineAffording Our Future, Wellington, December 2012N AT I O N A L H E A LT H C O M M I T T E E
2 0 1 5
NATIONAL HEALTH COMMITTEE
Statutory Advisory Committee responsible for providing the New Zealand Minister of Health with independent, evidence based recommendations on: Which technologies should be publicly funded To what level and where technology should be provided How new technology should be introduced and old
technology removed
So as to provide New Zealanders with the most effectivehealth services within the public health budget
N AT I O N A L H E A LT H C O M M I T T E E 2 0 1 5
WHAT ARE WE TRYING TO ACHIEVE?
High quality health, wellbeing and independence outcomes for individual patients and populations
Evidence based value for money Sector sustainability Enhanced health contribution to GDP growth
The NHC will be remembered for how it contributes to the first three goals – “bending the cost curve” through
technology adoption and management
Sustainability: Continuing to provide the range and types of services (outcomes) currently available, or better, without incurring excessive levels of taxes and / or debtVfM = measurable health outcomes / $ value resources invested
N AT I O N A L H E A LT H C O M M I T T E E 2 0 1 5
NHC PROGRAMME BUDGET2013 NHC ANALYSIS OF 2010–2013 NMDS
Source: NHC Strategic Business Plan 2014/15-17/18
Newborns $102M
Infectious $73M
Blood $32M
Pregnancy $219M
Nervous system $84M
Respiratory $274M
Female reproductive $75M
Ear, Nose, Throat $79M
Digestive $325M
Skin $132M
Male reproductive $19M
Hepatobiliary $98M
Circulatory $535M
Kidney & urinary $106M
Neoplastic $110M Musculoskeletal $296M
Burns $1M
Endocrine $92M
Eye $60M
Alcohol $4MMental $1M
0
2
4
6
8
10
12
0 10 20 30 40 50 60 70
Mean Price ($1000s)
Individuals (n, thousands)
Decay (<0%) Low growth (0<2%) L-M growth (2<4%) M-H growth (4-8%)Three year growth:
N AT I O N A L H E A LT H C O M M I T T E E 2 0 1 5
TECHNOLOGY MANAGEMENTSTREAMS AND TOOLS
Streams•Proactive Work streams•Reactive Referrals•Pull model
Tools•Sector Programme Budget•Tiered business cases •Notional Budget•Sector annual referral round•Innovation fund, HRC &CI
N AT I O N A L H E A LT H C O M M I T T E E 2 0 1 5
NHC APPROACH: MODEL OF CARE
Disease Groups
Population Groups
Models of Care (Systems Design)
Technologies
N AT I O N A L H E A LT H C O M M I T T E E 2 0 1 5
Most effective mix oftechnologies and clinical services
MODELS OF CARE
Feasibility
Societal & ethical considerations
Clinical safety & effectiveness
Economic
General populati
on
At risk of
condition
Has the condition (few co-
morbidities)
Advanced condition, multiple
comorbidities
End-stage
condition
APPROACH: BOTH LEVERAGING WHAT WE HAVE AND NEW TECHNOLOGIES FOR HIGH BENEFIT/HIGH VALUE
Old
+New
Combining what we have in new creative ways
Adding disruptive new technologies
Adoption Conditions
N AT I O N A L H E A LT H C O M M I T T E E 2 0 1 5
OUR PARTNERS
Extending the proactive work programme to work with industry
Eight HIP grants focussed on
COPD, IHD and EGFR
Pull into the sector
disruptive technologies
Capture the spill over
effects from technology diffusion
N AT I O N A L H E A LT H C O M M I T T E E 2 0 1 5
WORK STREAM TIMING
Musculoskeletal / Eye
Hepatobiliary / Kidney and Urinary (TBC)
Respiratory -> Chronic Obstructive Pulmonary Disease
Cardiovascular ->Ischaemic Heart Disease
Neoplasm / Endocrine
Genomics ‘Omics’
Digestive / Mental Health (TBC)
2013 2014 2015 2016 2017 2018
Frail elderly
Age-related macular degeneration, low back pain & IORT
Diagnostics -> Haematuria
Aortic Abdominal Aneurysm
2014/15 Reactive Referrals
Disease Population Models of Care (System)
Cardiac Cluster
Have we got it right?Are there specific developments in these areas?
Key
Intended proactive workstream
2014/15 reactive referral
2012/13 reactive referral
Proactive workstream
2013/14 reactive referral
Leading cause of vision loss and blindness in adults over the age of 50 At least 30,000 New Zealanders are affectedPrevalence expected to x2 in next 20 yearsCosts per annum (N = 13,000)
$20.5 million$41 million$205 million
N AT I O N A L H E A LT H C O M M I T T E E 2 0 1 5
AGE RELATED MACULAR DEGENERATION
AMD MODEL OF CARE
Population: Progressive dry AMD or suspicion of wet AMD Setting: Outpatient ophthalmology
Population: Stable early to intermediate dry AMD Setting: Community optometry
Population: Late dry AMD (GA) Setting: Outpatient ophthalmology
Population: Wet AMD Setting: Outpatient ophthalmology Population: Wet AMD Setting: Inpatient treatment
Diagnosis of wet AMD
N = 115,000-165,000 Costs = $4.3-$6.2M
Presents to optometrist (may by GP referral). − Patient history, VA, fundus assessment
(SBM)
− 2-yearly VA and fundus assessment by optometrist
Referral from optometrist or directly from GP or other health service if sudden loss of vision/distortion or other symptoms − VA and fundus assessment (OCT,
fundus photos or AF +/- FFA +/- ICG)
Symptoms or progression necessitating referral to an ophthalmologist
N = 14,000-42,000 Costs = $3M-$8M
N = 5000-10,000 Costs = $0.5M-$1M
N = 9000-18,000 Costs = $4M-$8M
- AREDS treatment - VA and fundus assessment +/- AF
N = 1500 Costs = $4.5M
Diagnosis of intermediate to late dry AMD
Population: Low vision Setting: Outpatient and community
− Assessment for treatment (VA, OCT, fundus photos +/- FFA +/- ICG)
− Treatment options o Anti-VEGF o Photodynamic therapy o Laser photocoagulation o Treatment futile
- Low vision rehabilitation - Blindness equipment and support
N = 6000 Costs = $3.7M Low vision or blindness not
amenable to treatment (advanced wet or dry AMD)
Diagnosis of early AMD
Asymptomatic, stable Early IdentificationRisk Stratification
Anti-VEGF
Low VisionRehabilitation
N = 14,000 - 42,000Costs $12 - $21.5M
N = 115,000 - 165,000Costs = $4.3 - $6.2M
N = 6000Costs = $3.7M
N AT I O N A L H E A LT H C O M M I T T E E 2 0 1 5
Public Education & Awareness
Low vision rehabilitation
Prevention
Activity
Ophthalmology Prioritisation
Tool
Intravitreal Anti-VEGF Treatment
Primary and community care Secondary care Palliative care
Ministry National Health Board Business UnitLow Vision Services Service Development
PopulationScreening
Measurable health, wellness and independence gains for patients and populations
Workforce
Information
Capital investment
Purchase and procurement goods and services
Costs and funding bundles
PHARMAC Aflibercept
Assessment
Trained Nursing staff delivering
intravitreal treatments
AMD genomic diagnostic risk stratification
HWNZ Optometry & Ophthalmology scope of practice
NZBF AMD prevalence
Study
Funding Streams incentives and disincentives
Equipment in the community
AMD GENOMIC DIAGNOSTIC - RISK STRATIFICATION
N AT I O N A L H E A LT H C O M M I T T E E 2 0 1 5
WHERE TO FROM HERE?
Direct-to-Consumer Personal Genome Testing for Age- Related Macular Degeneration
‘CONCLUSIONS. Direct-to-consumer personal genome tests are not suitable for clinical application as yet. More comprehensive genetic testing and inclusion of environmental risk factors may improve risk prediction of AMD’
Invest Ophthalmol Vis Sci. 2014;55:6167–6174. DOI:10.1167/iovs.14-15142
N AT I O N A L H E A LT H C O M M I T T E E 2 0 1 5
23andMe, deCODEme, Easy DNA, Genetic Testing Laboratories
In that study serum free thyroxine levels were positively associated with development of AMD
The Economic and Functional Impacts of Genetic and Genomic Clinical Laboratory Testing in the United
States. American Clinical Laboratory Association 2012
• 116,000 U.S. jobs$6 billion in personal income for U.S. workers
• $9.2 billion in value-added4 activity• $16.5 billion in national economic output
N AT I O N A L H E A LT H C O M M I T T E E 2 0 1 5
DISRUPTIVE COMPOSITE BIOMARKERHAEMATURIA MODEL OF CARE
.
Investment
.
Investment
Cxbladder
.
N AT I O N A L H E A LT H C O M M I T T E E 2 0 1 5
PULL MODEL AND EMBED MODEL
Extending the proactive work programme to work with industry
Eight HIP grants focussed on
COPD, IHD and EGFR
Pull into the sector
disruptive technologies
Capture the spill over
effects from technology diffusion
N AT I O N A L H E A LT H C O M M I T T E E 2 0 1 5
INNOVATION FUNDTHE PAYERS’ PROCUREMENT LIFECYCLE
• NHC’s forecasts
• Priority setting
• Planning• Care
Models• Business
problem
5-15 years
Needs
Identification
• Sounding board
• Solutions considered
• Engage research community
3-10 years
Ideation &
Research
• Develop and apply “disruptive” technologies
• CI grants
2-5 years
Commercial
Vehicles
• Generate evidence
• Watching brief
2-5 years
Clinical Trials
• NHC Innovation Funding
•1-3 years
DHB Case for Change(Fiel
d Trials)
• Sector adoption
• Product development for global market
0-ongoing
Market
Penetration
Ensuring:• The pipeline of emerging technologies aligns with
New Zealand payers’ priorities• The NHC’s advice is accepted and adopted• High impact
National Health CommitteeCallaghan Innovation
• Product Procurement
0-3 years
• Product utilised
Ongoing
Strategic Procurement
• Horizon scanning
• Strategic relationship management3-10 years
N AT I O N A L H E A LT H C O M M I T T E E 2 0 1 5
PULL AND EMBEDNZ GOVERNMENT INFRASTRUCTURE
FUTURE DEMAN
D SIGNAL
S(NHC)
GOVT. RESEAR
CH FUNDIN
G PRIORIT
IES(HRC)
PAYER CURREN
T & FUTURE SPEND(DHBs)
BUSINESS DEVELOPMENT AND
R&D GRANTS
(CALLAGHAN)
REGULATORY AND
CASE FOR CHANGE
(NHC)
N AT I O N A L H E A LT H C O M M I T T E E 2 0 1 5
NHC Terms of Reference Section 6.2 (b) an understanding, and the skills and experience to ensure, that better national stewardship of the investment in health technology and services will lead to enhanced service delivery for all New Zealanders within the resources available
Responsibilities of doctors in management and governance
www.mcnz.org.nz 2011
N AT I O N A L H E A LT H C O M M I T T E E 2 0 1 5
WISE STEWARDSHIP OF HEALTH CARE RESOURCES
The Institute of MedicineBest Care at Lower Cost: The Path to Continuously Learning
Health Care in America, 2012
• Approximately 30% of U.S. healthcare is duplicative or unnecessary
• Inappropriate or over-utilized medical tests account for $250 to $300 billion in U.S. medical expenses each year
• Inappropriate testing not only compromises the quality of care but, in some cases, may pose risk or harm to patients by leading to more testing and unnecessary procedures or medication
N AT I O N A L H E A LT H C O M M I T T E E 2 0 1 5
CHOOSING WISELY
American Board of Internal Medicine Foundation boldly invited professional societies to own their role as “stewards of finite health care resources”
“Five Things Physicians and Patients Should Question”
N AT I O N A L H E A LT H C O M M I T T E E 2 0 1 5
N AT I O N A L H E A LT H C O M M I T T E E 2 0 1 5
• Do not perform population-based screening for 25-OH- Vitamin D deficiency.
• Do not perform low-risk human papillomavirus (HPV) testing.
• Avoid routine preoperative testing for low-risk surgeries without a clinical indication.
• Only order methylated septin (SEPT9) on patients for whom conventional diagnostics are not possible.
• Do not use bleeding time tests to guide patient care.
N AT I O N A L H E A LT H C O M M I T T E E 2 0 1 5
CHOOSING WISELY
Choosing Wisely – The Politics and Economics of Labeling Low-Value Services.N Engl J Med. 2014 February 13, 370 (7): 589-592. doi.1056/NEJMp1314965.
LABORATORY SERVIC
ES
N AT I O N A L H E A LT H C O M M I T T E E 2 0 1 5
AN OVERVIEW OF LABORATORY SERVICES IN NEW ZEALAND
Encouraged by the sector to take a more strategic approach particularly relating to: workforce planning and career pathways long term contracting, including public / private partnerships national processes to assess new tests and research into
new tests and unnecessary testing Working with the Ministry of Health’s National Laboratory
Roundtable to develop a more robust Overview document to inform strategic medium to long term national planning
Working with the medical profession through the Council of Medical Colleges engaging in Choosing Wisely
N AT I O N A L H E A LT H C O M M I T T E E 2 0 1 5
Sector Outcomes
Sector Level
NHC Impact
NHC Strategy
NHC Strategic Functions
Improved patient & population
health outcomes
Improved sector sustainability
Sector contribution to
economic growth
Whole of government
systems thinking
Bending the cost curve
Contribution to economic growth
through innovation
Most effective mix of clinical
services delivered
Finding the balance
Applying the full extent of the
NHC mandate
Leading & influencing
sector change
Identify / Prioritise / Advise /
Recommend
Implement Monitor / Evaluate
Innovate
Model of care approach – integrated prioritisation across the continuum of clinical and business decision making
Intervention Level Prioritising the best mix of clinical services to meet current & future need
and maximise health outcomes
Improved patient & population
outcomes
Whole of Government Outcomes Improved population health
& wellbeing
Better Public Services
Improved economic growth
for NZ
Sector Priorities Clinical Leadership
Financial sustainability
Integration Health Targets
FOUR YEAR STRATEGIC PLAN
N AT I O N A L H E A LT H C O M M I T T E E 2 0 1 5
National Health Committee 2015
MULTI CRITERIA DECISION MAKING METHODOLOGIES MEGA ANALYSIS
Specific Weighted Outcomes Clinical safety and effectiveness Health and independence gain Materiality Feasibility of adoption Policy congruence Equity Acceptability Cost effectiveness Affordability Risk
Evidence: level of certainty / assumptions / risk HighModerateLowVery low
Dynamic!Systems!
Medium to long term horizon!
N AT I O N A L H E A LT H C O M M I T T E E 2 0 1 5
TOOLS - TIERED BUSINESS CASES
Source: NHC Strategic Business Plan 2015/16–2018/19
CLINICAL ADVICE & ENGAGEMENT SECTOR ADVICE & ENGAGEMENT NHC PRIORITY AREAS
Tier 1: Strategic OverviewOutputs:Committee recommendations for T2Published document
Tier 2: Sub-Area AnalysesOutputs:Committee recommendations for T3
Tier 3: AssessmentsOutputs:Assessment reports
Outputs:Published recommendations Supporting assessment reports
Outputs:Recommendations to Minister of Health Supporting documentation
College/Society nominations of key investment / reprioritisation opportunities
ADVICE
ENGAGEMENT
College/Society membership to gain support / approval
NHC presentation to Clinical Leaders on:- Indicative priority sub-areas- Sector Working Group membership- 'Choosing Wisely' input
Production and Dissemination of Information to Clinicians and Patients
Health Sector Forum, DHB CEOs and Chairs through NPRG
Colleges and Speciality SocietiesProgramme Budget, Models of Care &
Surveillance
SECTOR IMPLEMENTATION
NHC MonitoringNHC Evaluation
(as required)
Committee RecommendationFormulation
Committee RecommendationFormulation
Priority Area
Recommendationsto Minister
More detailed analysis
Advisory and Working Groups
Implementationand Analysis
N AT I O N A L H E A LT H C O M M I T T E E 2 0 1 5
NATIONAL HEALTH COMMITTEE AND CALLAGHAN INNOVATION WORKING TOGETHER
• NHC’s forecasts
• Priority setting
• Planning• Care
Models• Business
problem
5-15 years
Needs
Identification
• Sounding board
• Solutions considered
• Engage research community
3-10 years
Ideation &
Research
• Develop and apply “disruptive” technologies
• CI grants
2-5 years
Commercial
Vehicles
• Generate evidence
• Watching brief
2-5 years
Clinical Trials
• NHC Innovation Funding
•1-3 years
DHB Case for Change(Fiel
d Trials)
• Sector adoption
• Product development for global market
0-ongoing
Market
Penetration
Making the commercialisation of medical technologies and services easier - and at the same time improving health system outcomes
National Health CommitteeCallaghan Innovation
How do we strengthen this process so that it contributes more effectively to the health system’s continuing capacity to deliver the health outcomes New Zealanders expect - despite emerging pressures and tight fiscal realities - through the adoption of right-headed innovations?
N AT I O N A L H E A LT H C O M M I T T E E 2 0 1 5