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College aantekeningen Health Technology Assessment (GW4546M)
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Health Technology-Assessment Lecture 1Introduction in HTA/economic evaluation
In this course you will learn:
1. …how to conduct an economic evaluation
2. …to understand and recognize (international) differences in HTA methodology
3. …to assess the quality of an economic evaluation and interpret the results
4. …to understand the relationship between HTA and policy (and the decisions made by policymakers).
HEPL/HE: Improving healthcare and health policy
In the master there are several questions that we will face. The courses are linked to these questions. In this course
we will deal with the question above.
• What challenges do health policy makers face?
Right now, we see that there is a discussion about priorities in healthcare and this has to do for instance with
the personal that is available, in the end this all comes down to the fact that the resources are limited and
that choices need to be made. In health care, these choices are really complicated and difficult and that is
one of the reasons for this course. A proper HTA can help to make informed choices.
• What options exist for health policy?
It is all about policymaking and the choices that they face and the option that they have. For instance, HTA is
about rationing the basic benefits package. And this is just one option that policymakers have. They can have
a look at all new technologies and treatment by doing an HTA to examine what the costs and benefits of
these new technologies are. At the same time, they can also decide to ration demand or supply, because
there are other options that they can use. HTA is one of the options that policymaker can use to choose how
to spend the limited resources.
• How can economic thinking help understand the behaviour of patients, providers, payers and policy
makers?
We will also look at economic theory and how the behavior of patients, providers and payers in health care
influences their behavior.
• How do different healthcare systems perform?
• How is policy shaped?
Although, HTA is very important, it is only part of what policy is shaping. We will see that later on in this
lecture. HTA just part of the policy making process.
• What are the legal conditions for health policy?
• How should empirical research in healthcare be conducted and interpreted?
The exam will exist out of 4 questions which are some essay questions and some calculations that we have to
make.
We cannot put endless money in health care. In the end people can no longer afford it. We can discuss when we’ll
say that we cannot afford it anymore, but there are already decisions made in health care and other sectors (like
traffic) where monetary arguments are used to actually reimburse something or not. If we make this explicit, it can
be very complex. But at least, we have then the information about what we’re giving up and what we’re getting
back. This is where we will talk about this course.
Usually, what people have to do in health care, is that they have to make a decision in different types of drugs. This
is where the ethical part is even more complex, because then we have two different patients’ group. Imagine that
we have a certain fixed health care budget, and you have to decide whether you have to reimburse treatment A or
treatment B. Would you reimburse the drug for breast cancer of the drug for Duchenne?
If a disease is very severe, then people can decide to reimburse it. It is really hard to choose between those two
treatments. Both videos are about real patients that depend on the drug and that could potentially benefit from it.
Therefore, it is really though to choose. With a HTA we will try to at least provide information about all the costs that
are associated with a new treatment and all the effects that are associated with a new treatment, so that at least an
informed choice about this difficult trade-off can be made.
,Good news… and bad news…
As we have seen, based on the videos, it is difficult to make choices in HTA, because there are different opinions
about which drug to reimburse. Some would prefer cost-effectiveness while other doesn’t prefer this. Good news is
that the LE is increasing, but we also see some bad news because the costs are increasing as well.
Most healthcare spending is public
Most of the healthcare expenditures are public expenditures. And if expenditures are public, this means that
decisions have to be made publicly. In this graph, we can see that there is a sharp increase in the Netherlands of the
public health expenditures. This is due to a different way of financing. In the past we used to have public and private
insurance, and this became a social insurance. Most of the money is now publicly spent in health care in the
Netherlands. But if we see that more of 85% of the money in healthcare is publicly spent, then someone needs to
decide how we’re going to spend this money.
More bad news…
• Resources are scarce
• We can only spend money once
• Money spent on technology A cannot be spent on technology B
• Money spent on health care cannot be spent on education, infrastructure etc.
We see now with the Covid-19 crisis, that this choice where to spend the money on is really actual. If we decide to
spend all our money on treating Covid-19 patient, we cannot spend the same recourses on treating other patients.
,To reimburse or not to reimburse?
• Resources in health are limited
• Decisions regarding reimbursement have far reaching consequences
Today’s lecture
Learning objectives
• Why HTA
• What is HTA
• Understanding the basic concept of economic evaluations
• Knowing the steps in conducting an economic evaluation
• Medical costs and economic evaluations
During this course, we will walk through all the steps of an HTA. This is the first lecture where we’ll be introduced to
the steps and in the rest of the lectures, we will be provided more details about all the steps.
Why HTA?
• Health care expenditures increase
→ Is this a problem?
→ What happens is we reimburse every treatment?
→ Positive + negative consequences
Other options?
If choices in health care have to be made…
It is better to make informed choices!
The core of HTA is that if choices in health care have to be made, then it is better to make informed choices. By
making informed choices, you have at least information that decisions can be made on, and you can be accountable
for your decisions This is where HTA is aiming for.
Health Technology Assessment (HTA)
• Important advisory/policy tool → make transparent and unbiased decisions
It is an important tool that provides decisionmakers with the important information about all the potential
costs and outcomes, that are associated with reimbursing a new technology.
• Compulsory for deciding on reimbursement in many countries
This number is increasing. In drug treatments, we see that pharmaceutical companies for example, need to
show an economic evaluation of their product. This is the case in the UK, the Netherlands etc. And we also
see that this is increasingly requested for other health technology. So, not only for drug treatments anymore
but also for other technologies, like new radiotherapy. In the Netherlands, there is a new way of
radiotherapy introduced and the license for providing this treatment was associated with an obligation to do
cost-effectiveness research. So, they are allowed to use the new type of radiotherapy, but they need to
collect information and show the cost-effectiveness of the therapy after a couple of years.
• Assure value for money
The ultimate goal of using HTA in policy decision, is to assure that we will get most the for the money that
we spent. We want the most health effects for the resources that we have.
Definition
Health Technology Assessment (HTA)
HTA is the systematic evaluation of properties, effects and/or impacts of health technologies and interventions. It
covers both the direct, intended consequences of technologies and interventions and their indirect, unintended
consequences. = WHO definition
The fact that it is systematic means that all new technologies are evaluated in the same way. The second part is
important of this definition. We will have a look later on to see what this exactly means, because we have to include
several costs categories. Sometimes it can be that a new technology also has unintended impacts on other health
care sectors. For instance, if people early discharged from the hospital, this can have an impact on, for example, the
productivity of people who are living with a patient and who has to take care for the patient. In this case, the patient
is early discharged which may reduce the hospital costs, but it may increase productivity losses of other people. And
that is why we want to include all the intended and unintended, direct and indirect, consequences of technologies.
, Economic evaluation is usually the core
→ Compare two alternatives regarding costs and benefits
An economic evaluation is the core of HTA, but it is not the only thing. Doing an economic evaluation is part of the
HTA, but in a full HTA we also have to look at the organizational aspects, for example for implementing the new
technology. We will learn more about this during lecture 7.
Economic evaluations
• Economic evaluations provide insight costs and effects of
• (new) Interventions
• Compared with existing interventions
• Economic evaluations are everywhere
Economic evaluations are everywhere, not only in health care. If you want to drink something, you have a several
number for cokes. But we can also decide to choose another brand. If you have to make a decision, you can take a
look at the effects about what the different types of cola gives us. Thereby, we can also have a look at the costs. Or
we can take a look at a completely other competitor, like another drink.
Phases in performing an economic evaluation study
Question discussion board: Not everything that we think is important is possible to measure appropriate or quantify.
If we cannot do this, is HTA than still the optimal tool for decision-making?
Yes. If there are certain aspects that we think are relevant, for example the severity of the disease, then ideally, we
would like to take this into account in the HTA. In HTA, researchers are trying to quantify things that are seems to be
impossible to quantify. For example, severity of the diseases they try to quantify by measuring how many years
people lose or how many quality adjusted life years do people lose. So, if there are for example two types of
diseases, you can try to measure quality of life for patient A and we can compare this with the quality of life of
disease B. So, HTA-researchers are really trying to do their best to quantify everything, because the advantage of
quantifying is that you can make it comparable to other treatments. Some of the treatments will aim to improve
lives and some of the treatments will aim to improve life duration. If we can quantify this, the advantage is that the
decisions can be made transparent and it can be comparable over different technologies. If we cannot quantify this,
we can still decide to reimburse a treatment. If we see that a treatment is not cost-effective, but they still think that
this patient group needs to be helped, they can use the informative measurements that are being quantified from an
HTA. But they can also report the policymakers, that item A, B and C are also considered relevant, but it is not
possible to quantify this. At least, they can take it into account and based on the HTA they can still decide to
reimburse treatments that are not cost-effective.
These comparisons are exactly what we’re going to do with new technologies. These are the 6 phases in performing
an economic evaluation. We will walk briefly through them today.
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