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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
Health Economics & Health Technology Assessment 2
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
Health Economics & Health Technology Assessment 3
1. HTA guideline
Health Economics & Health Technology Assessment 4
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
Health Economics & Health Technology Assessment 5
3. Low-value lists
Health Economics & Health Technology Assessment 6
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)
Health Economics & Health Technology Assessment 7
5. Guideline review
Example – CG34 Hypertension – savings from less
cardiovascular events if more drugs prescribed-£447,000
saved per £100,000 spent
Health Economics & Health Technology Assessment 8
6. Service redesign
‘centralisation’ ‘use of non-
clinical staff to deliver some
services…non-contentious
initiatives’ (Roosehenas et al, 2015)
Health Economics & Health Technology Assessment 9
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
Health Economics & Health Technology Assessment 12
DISINVESTMENT
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Health Economics & Health Technology Assessment 14
Health Economics & Health Technology Assessment 15
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Health Economics & Health Technology Assessment
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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Health Economics & Health Technology Assessment 18
NW NE
SW SE
INCREMENTAL
COST
INCREMENTAL EFFECTIVENESS
The cost-effectiveness
plane – kinked threshol
Drug C
Threshold value for
ICER
Drug A
Drug D