Canadians are missing out on the health and wider societal benefits of new healthcare technologies because of our country’s overly simplistic drug evaluation process. In adopting a narrow health system perspective and in focussing its assessment of value exclusively on a single parameter known as the cost per quality adjusted life year ($/QALY), the current Health Technology Assessment (HTA) process used in Canada fails to account for other variables that can greatly affect patient outcomes and add to the overall societal value of a medication.

While it may be appealing in its perceived simplicity and purported objectivity, the $/QALY is neither simple nor objective. Its calculation requires complex modeling and a myriad of accompanying assumptions. In reality, at its very best it should be considered a mere estimation, comprising a wide distribution of possible values. Which value most closely approximates “reality” depends largely on the perspective of the observer and which assumptions they choose. In other words…it is highly subjective. Why then does our current HTA process resign itself almost exclusively to this mediocre surrogate for value? Proponents will argue that it is the best of a bad lot. But this seems to me to be too convenient a response when one considers the profound impact that reimbursement decision making has on the health of individuals and our society. No doubt the decisions in question are difficult. But decision makers and those around them have an obligation to constantly improve upon their methodology and to conduct their evaluations from the perspective of society overall, not simply that of the health system budget silo.

A truly comprehensive HTA process should account for variables other than $/QALY and should strive to incorporate factors from outside of the health system. The objective of this approach should be to compliment and improve traditional HTA; not replace it.

At Amgen, we believe that if the framework used to assess new drugs is to evolve, it is essential to stimulate debate and dialogue among stakeholders, including patients, healthcare providers, academics and governments. We have conducted research that looks at alternative models for decision-making in other parts of the world and found that multi-criteria decision-making is used effectively in such countries as France, Italy and Sweden.

In work reported in Health Economics, Goldman and colleagues described a model that supports the use of a broader definition of value¹. Called Comprehensive Benefits of Value, or CBV, this framework goes beyond traditional HTA considerations to assess such important factors as the level of innovation, societal benefits, disease severity, unmet need and enhanced patient experience. We believe this type of qualitative review in tandem with traditional HTA will ultimately help improve quality of reimbursement decision making.

It has been said that one could place all of the economists on earth end to end and that they still would not reach an agreement. This is no less true of their more specialized health economist brethren. But one thing health economists, healthcare providers, patients, governments and all other stakeholders must absolutely agree on is that the individual and societal consequences of reimbursement decisions are profound. The weight of this responsibility compels all involved to subject the decision making apparatus to unrelenting scrutiny and debate and to strive for continuous improvement. It is a mission in which “failure is not an option”.

More information on Novel Frameworks for Reimbursement Decision Making.

Reference:
¹ Goldman D, Lakdawalla D, Philipson T, and Yin W. Valuing Health Technologies at NICE: Recommendations for improved incorporation of treatment value in HTA. Health Econ. 19:1109-1116(2010)