The Covid-19 pandemic has accelerated the crisis of healthcare sustainability. Prior to the emergence of the novel coronavirus, policymakers argued that healthcare systems were not sustainable in the long run in terms of the resources necessary to support equitable patient access to high quality healthcare. Covid-19 has compounded this problem of sustainability.
Across the globe, health technology assessment (HTA) entities have been addressing sustainability by designing value frameworks to align payments for medical technologies with health outcomes. But, some have questioned whether patients are sufficiently involved in the design and implementation of value frameworks. We hear a lot about how healthcare systems ought to be patient-centric. Yet, to what degree is the patient’s voice incorporated in value assessment by value frameworks, and in the ultimate decisions that impact the patient?
In research sponsored by the Drug Information Association of Europe and Boston Consulting Group we analyzed the ability of eight value frameworks* operated by HTAs, medical professional societies, hospitals, and patient advocacy groups, to achieve the dual aim of sustainable healthcare funding and incorporation of patient-centered preferences and outcomes. Separately, we assessed how value-based contracts established by public and private payers can be both sustainable and patient-centric.
Here, sustainability is defined as the ability to fund new innovations now and in the future, in such a way as to ensure that patient access to quality care is optimized across the entire healthcare value chain. Patient centricity refers to inclusion of patient input (preferences) in value assessment, as well as incorporation (translation) of patient-centric outcomes in clinical and economic decisions.
Rising healthcare costs have been a driving force behind the emergence of a plethora of value frameworks. Value frameworks assess the costs and benefits of (new) medical technologies. Benefit attributes include reduction of symptoms, improvement of functioning, quality of life, and life expectancy, taking into account possible toxicity and side effects related to use of the medical technologies in question.
Several health technology assessment entities that operate distinct, yet similar value frameworks feature prominently in the news, such as the Institute for Clinical and Economic Review (ICER) in the U.S. and the National Institute for Health and Care Excellence (NICE) in the U.K.. Others are not as visible or well-known, including the Institute for Quality and Efficiency in Healthcare (IQWIG) in Germany and the Swedish Dental and Pharmaceutical Benefits Agency (TLV). Still others that use value frameworks are not HTAs per se. Rather, a number of value frameworks have been designed under the aegis of medical professional societies, hospitals, and patient advocacy organizations.
We surveyed and held a roundtable with 22 key opinion leaders representing the pharmaceutical and health insurer industries, academia, and patient advocacy. They were all (at least somewhat) familiar with all 8 selected value frameworks. We also provided the survey respondents with vignettes describing the frameworks in brief.
Of the 8 value frameworks analyzed, the survey indicated that three – Sweden’s TLV, U.S.-based ICER, and U.K.-based NICE – were closest to achieving the dual aim of improved sustainability and patient centricity. The ICER and NICE value frameworks yielded very similar survey results, so we combined them in the table below. Between 45% and 50% of respondents believed the three frameworks would improve sustainability. And, between 45% and 65% of respondents thought that the frameworks incorporated patient preferences and reported outcomes. Nevertheless, half of the respondents indicated that the ICER and NICE frameworks did not incorporate all relevant factors in their value assessment.
Separately, we analyzed value frameworks incorporated by public and private payers in so-called risk-sharing agreements and value-based contracts. These frameworks did a better job at sustainability, but were less patient-focused.
Ideally, value frameworks and value-based payment systems for healthcare services follow a sustainable and patient-centric path. But, at present, none of the value frameworks we analyzed are equipped to achieve high degrees of both improved sustainability and patient-centricity. In particular, survey respondents suggested there may be deficiencies in how the patient voice is captured by value frameworks, and then translated into decision-making.
Roundtable participants indicated that while HTAs view patient-related outcomes as “influential” to understanding the benefit side of the equation from the patient perspective, they are not consistently used in the appraisal of evidence on effectiveness and safety.
Part of the problem, according to roundtable participants, is the difficulty of finding a consensus around key value endpoints across all key stakeholders, including patients.
There is no easy fix to building a consensus around value endpoints that satisfy all stakeholders’ demands, including patients. To facilitate a more patient-centric approach, it would behoove policymakers systematically measure health outcomes that matter to patients, coupled with a calculation of the resources required to deliver those outcomes across the healthcare value chain. Current reimbursement approaches are often piecemeal and siloed, focusing on single elements, such as pharmaceuticals or diagnostics, rather than taking a holistic view across the entire healthcare value chain. Ideally, value frameworks break through this silo mentality; transcend the pharmaceutical, physician service, outpatient, and hospital siloes.
Here are some examples of adjustments to value frameworks that may lead to improved sustainability and patient-centricity:
– Patient Engagement: Establish more opportunities for value frameworks to incorporate patient input in value assessment, and ultimately in decision-making.
– Societal Perspectives: In addition to the payer perspective, it’s important to assess the societal impact of treatments, including items such as worker productivity and caregiver burden.
– Transparency: Commit to full transparency by making the value framework models used by HTAs publicly available so that interested stakeholders can understand the rationale behind the choices made in the assessments.
– Use of Different Cost-Effectiveness Thresholds: With those HTAs that deploy cost-effectiveness thresholds, having a single threshold for all disease categories may not lead to an equitable distribution of resources. So, for example, it may be more reasonable to set higher cost-effectiveness thresholds for drugs targeting rare diseases or those with greater disease severity or burden. In this vein, it’s also important to track the different outcomes and costs that exist for defined (stratified) population segments, rather than relying on averages. This is especially relevant in the age of precision medicine.
– Additional Elements of Value: Include benefits to patients that often do not have conventionally defined economic value; for example, convenience of use associated with certain new formulations, such as an oral rather than an injectable dose, or a single versus multiple tablet regimen. While some new formulations may merely be window dressing others have considerable value, particularly with respect to boosting patient adherence.
Currently, value frameworks appear to be lacking in terms of their ability to move healthcare systems towards both a highly sustainable and patient-centric pathway. In particular, there may be deficiencies in how the patient voice is captured in value assessment and translated into decision-making. Further adjustments to value frameworks may be needed to make them more patient-centric.