Geoff Sprang argues that traditional HTA misses the “big picture”. Traditional HTA is all about cost per QALY. Because this is inadequate, we need additional models of reimbursement decision making. He suggests that one such framework is the “Comprehensive Benefits of Value” framework, as described by Goldman. Several comments follow.

• Who is it that’s doing the asking, and why? Is this issue being raised now because the rate of reimbursement for new drugs is seen to be too low by industry? This type of motivation is suggested by the opening rationale, which expresses concern about Canadians’ inability to access new technology? Of course, this doesn’t mean that the questions being raised are not legitimate, but it is helpful to keep the broader agenda of this debate in mind.
• “Conventional HTA is all about cost per QALY gained”. If only it were so. There is, first of all, really no such thing as “conventional HTA”. To the extent to which there is a common ground, HTA is mostly about evidence synthesis, to a less extent about economic evaluation, particularly in Canada, and to some extent about the broader social and ethical considerations associated with technology. HTA is by definition a mongrel, with a mixed pedigree derived from evidence based medicine, health economics/decision analysis, and bioethics/social science. In Canada, most HTA decision making bodies are rooted in a tradition of evidence based medicine- an HTA will nearly always include an evidence synthesis or review, but not always an economic evaluation. Canadian decision making frameworks always include factors other than value for money. The framework of the Ontario Health Technology Advisory Committee, for example, includes four factors: i) Evidence of effectiveness and safety; ii) Social and ethical concerns; iii) Cost effectiveness; iv) Feasibility- system sustainability.
• What about drug reimbursement decision making in Canada? Is it really all about cost/QALY calculations? There’s no doubt that questions of value (one measure of which is incremental cost per QALY gained) play a larger role than they used to. But decision making around new drugs is highly complex, varies widely between provinces, and takes many other things into account. Nearly always, pride of place goes to effectiveness and safety. Health economic considerations are playing a larger role, as they should, in my view, but we are a long way, say, from the situation in the UK, where cost effectiveness plays a very substantial role. Economic analyses vary widely in quality, are nearly always conducted by those who have a large incentive to produce a particular result, and are poorly understood by decision makers. The role of health economic considerations, in my view, is still fairly modest in Canada.
• What about the role of “broader questions”- i.e. issues beyond effectiveness and cost effectiveness? Sprang has a point here- conventional analyses can be reductionistic, in that the presence of randomized trial evidence and a favourable cost effectiveness ratio are seen as “hurdles” that new technologies must surmount. HTA agencies and reimbursement groups globally are trying to work out how to include broader dimensions of value in decision making. Patients are sitting on guidelines committees and reimbursement decision making bodies. Citizens’ panels are proliferating. New methods are being explored to consider patients’ perspectives and values through primary and secondary research. This is a welcome, and overdue development. The danger, though, is lowering the bar. There is a tradeoff between considering broader perspectives and weakening the science. Allowing values and preferences to take a seat at the table may attenuate the influence of “conventional” considerations like, “does it work?”, and “is it a good deal?”. We need to work out how to include those considerations too- without weakening the scientific perspective that gives our current work its credibility.