Access to High-Cost Drugs: Decision Makers' Perspectives

Hospital drug and therapeutics committees in Australia: is there a role for economic evaluation at the institutional level?

Decisions about spending on medicines occur at different levels in the Australian health care system. This commentary describes the role of economic evaluation at the institutional (public hospital) level. In contrast to the decisions taken at the level of Federal subsidy (listing on the Pharmaceutical Benefits Scheme) formal pharmacoeonomic data analyses are usually not available, and arguably often not relevant to decision making within the public hospital setting. Future research is needed to develop and explore models of best practice and how to incorporate pharmacoeconomic evidence into local decisions.

Setting priorities for high-cost medications in public hospitals in Australia: should the public be involved?

AIM

To explore healthcare decision makers' perceptions about public involvement in setting priorities for high-cost medications (HCMs) in public hospitals in Australia.

METHODS

In-depth, semi-structured interviews were conducted with 24 decision-makers (executive directors of hospitals, area health service managers, directors of hospital pharmacy departments and senior medical doctors) in a Sydney Area Health Service. Interviews were digitally recorded, transcribed verbatim, thematically content analysed and coded.

RESULTS

The majority of participants perceived that the 'rationing debate' needs to happen in Australia. The community at large should be encouraged to understand that healthcare resources are limited and choices need to be made. The perspectives of the public, according to participants, were considered diverse (tax payers, patients, consumers). Owing to the complexities of the healthcare system, their involvement of the public in decision-making regarding access to HCMs in public hospitals was considered limited. For participants, the role of the public was likely to be at the macro level, deciding how much they were prepared to spend on healthcare.

CONCLUSION

The role of the public in setting priorities for HCMs in public hospitals was perceived by these healthcare decision makers as limited. However since rationing is unavoidable, there should be an explicit debate about the principles and issues concerned.

Resource allocation and health technology assessment in Australia: Views from the local level

Objectives:Several studies have shown that a key determinant of successful health technology assessment (HTA) uptake is a clear, fair, and consistent decision-making process for the approval and introduction of health technologies. The aim of this study was to gauge healthcare providers' and managers' perceptions of local level decision making and determine whether these processes offer a conducive environment for HTA. An Area Health Service (AHS) aimed to use the results of this study to help design a new process of technology assessment and decision making.

Methods:An online survey was sent to all health service managers and healthcare providers working in one AHS in Sydney, Australia. Questions related to perceptions of current health technology decisions in participants' own institution/facility and opinions on key criteria for successful decision-making processes.

Results:Less than a third of participants agreed with the statements that local decision-making processes were appropriate, easy to understand, evidence-based, fair, or consistently applied. Decisions were reportedly largely influenced by total cost considerations as well as by the central state health departments and the Area executive.

Conclusions:Although there are renewed initiatives in HTA in Australia, there is a risk that such investments will not be productive unless policy makers also examine the decision-making contexts within which HTA can successfully be implemented. The results of this survey show that this is especially true at the local level and that any HTA initiative should be accompanied by efforts to improve decision-making processes.

Priority setting for high cost medications (HCMs) in public hospitals in Australia: A case study

Health care providers (HCPs) are increasingly aware of pressures on funding for health care services, including high cost medicines (HCMs). Allocating resources to innovative and expensive medications is particularly challenging and the decision-making processes and criteria used to allocate resources to HCMs have not been widely described in the literature. This case study aimed to describe the operations of the first reported High Cost Drug Sub-Committee (HCD-SC) in a public hospital in Australia. In addition the study also evaluated the decision-making process using Daniel and Sabin's ethical framework of "accountability for reasonableness". Some lessons emerged from the description of the operations of the HCD-SC. Decisions were not solely based on effectiveness and cost. Additional factors such as "clinical need" and the lack of an alternative treatment were involved in decisions about access to HCMs. Members of the HCD-SC also considered it was important to have consistency in the way decisions were being made. The findings from this study provide an evidence base for developing strategies to improve this hospital's decision-making process regarding access to HCMs.

Public views on priority setting for high cost medications in public hospitals in Australia

OBJECTIVE

To gather information about views of members of the general public about access to High Cost Medications (HCMs) in public hospitals.

METHODS

A structured questionnaire was administered to members of the general public. Individuals were approached in train stations, shopping centres and different venues in the Sydney metropolitan area. People were eligible to answer the survey if they were: over 18 years of age, Australian permanent residents and able to complete the questionnaire in English.

RESULTS

Two hundred people completed the survey. Of these 56% were females, 47% were married, 84% spoke English at home, 88% were working either full-time or part-time, 61% had a university degree, 27% had a household annual income greater than 100,000 dollars and 68% had private health insurance. Participants considered factors such as treatment outcomes, quality of life and current health status when determining who should have access to HCMs. Participants wanted resources to be allocated to provide the 'greatest benefit to the greatest number of people'. Almost half the respondents did not want direct involvement in decision-making, however, 38% did.

CONCLUSIONS

The results offered support for indirect involvement through the development of a process to involve community members in discussion on policy on the provision of treatment and services within health-care institutions and specifically, to seek the views of members of the public on the provision of HCMs and expensive services within public hospitals.

Economic evidence at the local level : options for making it more useful

Like other countries, Australia has had some success in incorporating economic evidence into national healthcare decisions. However, it has been recognised that this coverage does not extend to the local hospital or health region level. An extensive body of research has identified barriers to the use of economic evidence at the local level, leading some commentators to suggest that economic evaluation should only be targeted at national decision-making bodies. Yet, local decision makers in Australia and elsewhere make important choices about the uptake and diffusion of healthcare technologies. We propose a number of interrelated options to address the barriers that currently prohibit the use of economic evaluation by local decision makers in many jurisdictions. These include wider dissemination of user friendly models, inclusion of assessments of the cost impact of interventions on various budgets, and the establishment of an authoritative body that ensures the production of high quality economic models. It is argued that these options can have a significant impact on the way economic evaluations are conducted, reported, disseminated and used.