Methods of disinvestment in health care?… · Soril LJJ, Niven DJ, Esmail R, Noseworthy TW,...

Health Economics & Health Technology Assessment

Methods of disinvestment in health care?

J Bouttell, O Wu, K Boyd, R Heggie, M Aitken,

V Wells

22 May 2019

Health Economics & Health Technology Assessment 1

Eight methods

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Specific guidelines on how to do disinvestment

or tools to assist:

▪Spain – GuNFT/Pritec (Mayer, 2015)

▪New Zealand – National Health Committee (Harris, SHARE 10, 2017)

▪Brazil - CONITEC

Identify Prioritise Decide Implement

1. HTA guideline

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1. HTA guideline

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Pharmaceutical Benefits Advisory

Committee – Australian version of

NICE/SMC (Mayer, 2015)

Disinvestment? (Haas, 2012)

▪Withdrawal of unsafe medicines

▪Replacement by manufacturers

▪Drugs falling into misuse

▪More recently – generics and

biologic/biosimilar replacements

2. Medicine optimisation

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3. Low-value lists

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Fixed budget, marginal, facilitated, implemented?

Lots of examples:

▪respiratory health interventions – Wales (Charles et al, 2016)

▪child health policy on Tayside (Donaldson and Ruta, 1996)

Rational disinvestment (Donaldson, 2010)

Link with optimisation work (Earnshaw, 2002)

4. Programme budgeting

marginal analysis (PBMA)

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5. Guideline review

Example – CG34 Hypertension – savings from less

cardiovascular events if more drugs prescribed-£447,000

saved per £100,000 spent

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6. Service redesign

‘centralisation’ ‘use of non-

clinical staff to deliver some

services…non-contentious

initiatives’ (Roosehenas et al, 2015)

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Atlas of Health Variation

7. Benchmarking and

clinical audit

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8. Commissioning

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Barriers to

disinvestment

Method Barriers

HTA guideline Sustainability/Loss aversion

Medicine optimisation Loss aversion

Low-value lists Implementation

PBMA Sustainability/Implementation

Guideline review Implementation

Service redesign Evidence/stakeholders

Benchmarking/clinical audit Resource/implementation

Commissioning Loss aversion/evidence

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DISINVESTMENT

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References

Atlas of Healthcare Variation available at https://www.isdscotland.org/products-and-services/scottish-atlas-of-variation/view-the-atlas/ accessed 16 May 2019

Charles JM, Brown G, Thomas K, Johnstone F, Vandenblink V, Pethers B et al. Use of Programme Budgeting and Marginal Analysis as a framework for resource

reallocation in respiratory care in North Wales, UK. Journal of Public Health September 2016;38(3):e352-e361

Day RT, Norman R, Robinson S. Challenges and opportunities for disinvestment in Australia. Journal of Health Organization & Management. 2016 Nov 21;30(8):1301-7.

Donaldson, C., Bate, A., Mitton, C., Dionne, F., & Ruta, D. (2010). Rational disinvestment. QJM, 103(10), 801-807. http://dx.doi.org/10.1093/qjmed/hcq086

Drummond M. Clinical guidelines: a NICE way to introduce cost-effectiveness considerations? Value in Health 19.5 (2016): 525-530.

Earnshaw

Haas M, Hall J, Viney R, Gallego G. Breaking up is hard to do: why disinvestment in medical technology is harder than investment (2012)

Harris C, Allen K, Ramsey W, King R, Green S. Sustainability in Health care by Allocating Resources Effectively (SHARE) 11: Reporting outcomes of an evidence-driven

approach to disinvestment in a local healthcare setting. BMC health services research. 2018 Dec;18(1):386.

Harris C, Green S, Elshaug AG. Sustainability in Health care by Allocating Resources Effectively (SHARE) 10: operationalising disinvestment in a conceptual framework for

resource allocation. BMC health services research. 2017 Dec;17(1):632.Lemos LLP, Guerra Junior AA, Santos M, Magliano C, Diniz I, Souza K, et al. The Assessment for

Disinvestment of Intramuscular Interferon Beta for Relapsing-Remitting Multiple Sclerosis in Brazil. PharmacoEconomics. 2018 01 Feb;36(2):161-73.

Mayer J, Nachtnebel A. Disinvesting from ineffective technologies: lessons learned from current programs. Int J Technol Assess Health Care. 2015;31(6):355-62.

Rooshenas L.”I won't call it rationing...": an ethnographic study of healthcare disinvestment in theory and practice. Social Science and Medicine. 128 (pp 273-281), 2015.

Ruta D, Donaldson C, Gilray I. Economics, public health and health care purchasing: the Tayside experience of programme budgeting and marginal analysis J Health Serv

Res Policy Vol 1 Number 4 October 1996

Soril LJJ, Niven DJ, Esmail R, Noseworthy TW, Clement FM. Untangling, Unbundling, and Moving Forward: Framing Health Technology Reassessment in the Changing

Conceptual Landscape. International Journal of Technology Assessment in Health Care. 2018 Jan;34(2):212-7.

127.

Soril LJJ, Seixas BV, Mitton C, Bryan S, Clement FM. Moving low value care lists into action: prioritizing candidate health technologies for reassessment using

administrative data. BMC Health Services Research. 2018 Aug 15;18(1):640.

Tversky A, Kahneman D. Advances in prospect theory: Cumulative representation of uncertainty. Journal of Risk and uncertainty. 1992 Oct 1;5(4):297-323.

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NW NE

SW SE

INCREMENTAL

COST

INCREMENTAL EFFECTIVENESS

The cost-effectiveness

plane – kinked threshol

Drug C

Threshold value for

ICER

Drug A

Drug D