NATIONAL HEALTH COMMITTEE PETER GUTHRIE AND ANNE KOLBE NATIONAL HEALTH COMMITTEE 2015.

NATIONAL H

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COMMITTEE

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DISCLOSURE INFORMATION Peter Guthrie BA LLB

General Manager National Health Committee

Anne Kolbe ONZM, MBBS (Hons), FRACS, FRCSEng (Hon), FCSHK (Hon), FRCSEd (Hon), MAICD

Chair National Health CommitteePaediatric SurgeonAdjunct Associate Professor, University of AucklandMember, HealthPACTMember, Hospital Advisory Committee, Auckland District Health BoardMember, Risk and Audit Committee, Whanganui District Health BoardCo-chair, Policy Working Group International Global Leaders in GenomicsPrevious: Director, Pharmaceutical Management AgencyPrevious: President Royal Australasian College of SurgeonsChair, Review South Island Neurosurgery, 2010

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Mirror, Mirror on the Wall, The Commonwealth Fund, June 2014

Source: OECD Health Data, 2012N AT I O N A L H E A LT H C O M M I T T E E

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GROWTH IN CORE CROWN HEALTH SPENDING HAS OUTSTRIPPED NATIONAL INCOME …

Core Crown health expenditure per capita and GDP per capita indexed real growth

Nicholas Mays, London School of Hygiene and Tropical Medicine Affording Our Future, Wellington, December 2012

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Nicholas Mays, London School of Hygiene and Tropical MedicineAffording Our Future, Wellington, December 2012N AT I O N A L H E A LT H C O M M I T T E E

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NATIONAL HEALTH COMMITTEE

Statutory Advisory Committee responsible for providing the New Zealand Minister of Health with independent, evidence based recommendations on: Which technologies should be publicly funded To what level and where technology should be provided How new technology should be introduced and old

technology removed

So as to provide New Zealanders with the most effectivehealth services within the public health budget

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WHAT ARE WE TRYING TO ACHIEVE?

High quality health, wellbeing and independence outcomes for individual patients and populations

Evidence based value for money Sector sustainability Enhanced health contribution to GDP growth

The NHC will be remembered for how it contributes to the first three goals – “bending the cost curve” through

technology adoption and management

Sustainability: Continuing to provide the range and types of services (outcomes) currently available, or better, without incurring excessive levels of taxes and / or debtVfM = measurable health outcomes / $ value resources invested

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NHC PROGRAMME BUDGET2013 NHC ANALYSIS OF 2010–2013 NMDS

Source: NHC Strategic Business Plan 2014/15-17/18

Newborns $102M

Infectious $73M

Blood $32M

Pregnancy $219M

Nervous system $84M

Respiratory $274M

Female reproductive $75M

Ear, Nose, Throat $79M

Digestive $325M

Skin $132M

Male reproductive $19M

Hepatobiliary $98M

Circulatory $535M

Kidney & urinary $106M

Neoplastic $110M Musculoskeletal $296M

Burns $1M

Endocrine $92M

Eye $60M

Alcohol $4MMental $1M

0

2

4

6

8

10

12

0 10 20 30 40 50 60 70

Mean Price ($1000s)

Individuals (n, thousands)

Decay (<0%) Low growth (0<2%) L-M growth (2<4%) M-H growth (4-8%)Three year growth:

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TECHNOLOGY MANAGEMENTSTREAMS AND TOOLS

Streams•Proactive Work streams•Reactive Referrals•Pull model

Tools•Sector Programme Budget•Tiered business cases •Notional Budget•Sector annual referral round•Innovation fund, HRC &CI

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NHC APPROACH: MODEL OF CARE

Disease Groups

Population Groups

Models of Care (Systems Design)

Technologies

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Most effective mix oftechnologies and clinical services

MODELS OF CARE

Feasibility

Societal & ethical considerations

Clinical safety & effectiveness

Economic

General populati

on

At risk of

condition

Has the condition (few co-

morbidities)

Advanced condition, multiple

comorbidities

End-stage

condition

APPROACH: BOTH LEVERAGING WHAT WE HAVE AND NEW TECHNOLOGIES FOR HIGH BENEFIT/HIGH VALUE

Old

+New

Combining what we have in new creative ways

Adding disruptive new technologies

Adoption Conditions

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OUR PARTNERS

Extending the proactive work programme to work with industry

Eight HIP grants focussed on

COPD, IHD and EGFR

Pull into the sector

disruptive technologies

Capture the spill over

effects from technology diffusion

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WORK STREAM TIMING

Musculoskeletal / Eye

Hepatobiliary / Kidney and Urinary (TBC)

Respiratory -> Chronic Obstructive Pulmonary Disease

Cardiovascular ->Ischaemic Heart Disease

Neoplasm / Endocrine

Genomics ‘Omics’

Digestive / Mental Health (TBC)

2013 2014 2015 2016 2017 2018

Frail elderly

Age-related macular degeneration, low back pain & IORT

Diagnostics -> Haematuria

Aortic Abdominal Aneurysm

2014/15 Reactive Referrals

Disease Population Models of Care (System)

Cardiac Cluster

Have we got it right?Are there specific developments in these areas?

Key

Intended proactive workstream

2014/15 reactive referral

2012/13 reactive referral

Proactive workstream

2013/14 reactive referral

Leading cause of vision loss and blindness in adults over the age of 50 At least 30,000 New Zealanders are affectedPrevalence expected to x2 in next 20 yearsCosts per annum (N = 13,000)

$20.5 million$41 million$205 million

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AGE RELATED MACULAR DEGENERATION

AMD MODEL OF CARE

Population: Progressive dry AMD or suspicion of wet AMD Setting: Outpatient ophthalmology

Population: Stable early to intermediate dry AMD Setting: Community optometry

Population: Late dry AMD (GA) Setting: Outpatient ophthalmology

Population: Wet AMD Setting: Outpatient ophthalmology Population: Wet AMD Setting: Inpatient treatment

Diagnosis of wet AMD

N = 115,000-165,000 Costs = $4.3-$6.2M

Presents to optometrist (may by GP referral). − Patient history, VA, fundus assessment

(SBM)

− 2-yearly VA and fundus assessment by optometrist

Referral from optometrist or directly from GP or other health service if sudden loss of vision/distortion or other symptoms − VA and fundus assessment (OCT,

fundus photos or AF +/- FFA +/- ICG)

Symptoms or progression necessitating referral to an ophthalmologist

N = 14,000-42,000 Costs = $3M-$8M

N = 5000-10,000 Costs = $0.5M-$1M

N = 9000-18,000 Costs = $4M-$8M

- AREDS treatment - VA and fundus assessment +/- AF

N = 1500 Costs = $4.5M

Diagnosis of intermediate to late dry AMD

Population: Low vision Setting: Outpatient and community

− Assessment for treatment (VA, OCT, fundus photos +/- FFA +/- ICG)

− Treatment options o Anti-VEGF o Photodynamic therapy o Laser photocoagulation o Treatment futile

- Low vision rehabilitation - Blindness equipment and support

N = 6000 Costs = $3.7M Low vision or blindness not

amenable to treatment (advanced wet or dry AMD)

Diagnosis of early AMD

Asymptomatic, stable Early IdentificationRisk Stratification

Anti-VEGF

Low VisionRehabilitation

N = 14,000 - 42,000Costs $12 - $21.5M

N = 115,000 - 165,000Costs = $4.3 - $6.2M

N = 6000Costs = $3.7M

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Public Education & Awareness

Low vision rehabilitation

Prevention

Activity

Ophthalmology Prioritisation

Tool

Intravitreal Anti-VEGF Treatment

Primary and community care Secondary care Palliative care

Ministry National Health Board Business UnitLow Vision Services Service Development

PopulationScreening

Measurable health, wellness and independence gains for patients and populations

Workforce

Information

Capital investment

Purchase and procurement goods and services

Costs and funding bundles

PHARMAC Aflibercept

Assessment

Trained Nursing staff delivering

intravitreal treatments

AMD genomic diagnostic risk stratification

HWNZ Optometry & Ophthalmology scope of practice

NZBF AMD prevalence

Study

Funding Streams incentives and disincentives

Equipment in the community

AMD GENOMIC DIAGNOSTIC - RISK STRATIFICATION

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WHERE TO FROM HERE?

Direct-to-Consumer Personal Genome Testing for Age- Related Macular Degeneration

‘CONCLUSIONS. Direct-to-consumer personal genome tests are not suitable for clinical application as yet. More comprehensive genetic testing and inclusion of environmental risk factors may improve risk prediction of AMD’

Invest Ophthalmol Vis Sci. 2014;55:6167–6174. DOI:10.1167/iovs.14-15142

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23andMe, deCODEme, Easy DNA, Genetic Testing Laboratories

In that study serum free thyroxine levels were positively associated with development of AMD

The Economic and Functional Impacts of Genetic and Genomic Clinical Laboratory Testing in the United

States. American Clinical Laboratory Association 2012

• 116,000 U.S. jobs$6 billion in personal income for U.S. workers

• $9.2 billion in value-added4 activity• $16.5 billion in national economic output

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DISRUPTIVE COMPOSITE BIOMARKERHAEMATURIA MODEL OF CARE

.

Investment

.

Investment

Cxbladder

.

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PULL MODEL AND EMBED MODEL

Extending the proactive work programme to work with industry

Eight HIP grants focussed on

COPD, IHD and EGFR

Pull into the sector

disruptive technologies

Capture the spill over

effects from technology diffusion

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INNOVATION FUNDTHE PAYERS’ PROCUREMENT LIFECYCLE

• NHC’s forecasts

• Priority setting

• Planning• Care

Models• Business

problem

5-15 years

Needs

Identification

• Sounding board

• Solutions considered

• Engage research community

3-10 years

Ideation &

Research

• Develop and apply “disruptive” technologies

• CI grants

2-5 years

Commercial

Vehicles

• Generate evidence

• Watching brief

2-5 years

Clinical Trials

• NHC Innovation Funding

•1-3 years

DHB Case for Change(Fiel

d Trials)

• Sector adoption

• Product development for global market

0-ongoing

Market

Penetration

Ensuring:• The pipeline of emerging technologies aligns with

New Zealand payers’ priorities• The NHC’s advice is accepted and adopted• High impact

National Health CommitteeCallaghan Innovation

• Product Procurement

0-3 years

• Product utilised

Ongoing

Strategic Procurement

• Horizon scanning

• Strategic relationship management3-10 years

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PULL AND EMBEDNZ GOVERNMENT INFRASTRUCTURE

FUTURE DEMAN

D SIGNAL

S(NHC)

GOVT. RESEAR

CH FUNDIN

G PRIORIT

IES(HRC)

PAYER CURREN

T & FUTURE SPEND(DHBs)

BUSINESS DEVELOPMENT AND

R&D GRANTS

(CALLAGHAN)

REGULATORY AND

CASE FOR CHANGE

(NHC)

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NHC Terms of Reference Section 6.2 (b) an understanding, and the skills and experience to ensure, that better national stewardship of the investment in health technology and services will lead to enhanced service delivery for all New Zealanders within the resources available

Responsibilities of doctors in management and governance

www.mcnz.org.nz 2011

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WISE STEWARDSHIP OF HEALTH CARE RESOURCES

The Institute of MedicineBest Care at Lower Cost: The Path to Continuously Learning

Health Care in America, 2012

• Approximately 30% of U.S. healthcare is duplicative or unnecessary

• Inappropriate or over-utilized medical tests account for $250 to $300 billion in U.S. medical expenses each year

• Inappropriate testing not only compromises the quality of care but, in some cases, may pose risk or harm to patients by leading to more testing and unnecessary procedures or medication 

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CHOOSING WISELY

American Board of Internal Medicine Foundation boldly invited professional societies to own their role as “stewards of finite health care resources”

“Five Things Physicians and Patients Should Question”

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• Do not perform population-based screening for 25-OH- Vitamin D deficiency.

• Do not perform low-risk human papillomavirus (HPV) testing.

• Avoid routine preoperative testing for low-risk surgeries without a clinical indication.

• Only order methylated septin (SEPT9) on patients for whom conventional diagnostics are not possible.

• Do not use bleeding time tests to guide patient care.

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CHOOSING WISELY

Choosing Wisely – The Politics and Economics of Labeling Low-Value Services.N Engl J Med. 2014 February 13, 370 (7): 589-592. doi.1056/NEJMp1314965.

LABORATORY SERVIC

ES

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AN OVERVIEW OF LABORATORY SERVICES IN NEW ZEALAND

Encouraged by the sector to take a more strategic approach particularly relating to: workforce planning and career pathways long term contracting, including public / private partnerships national processes to assess new tests and research into

new tests and unnecessary testing Working with the Ministry of Health’s National Laboratory

Roundtable to develop a more robust Overview document to inform strategic medium to long term national planning

Working with the medical profession through the Council of Medical Colleges engaging in Choosing Wisely

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Sector Outcomes

Sector Level

NHC Impact

NHC Strategy

NHC Strategic Functions

Improved patient & population

health outcomes

Improved sector sustainability

Sector contribution to

economic growth

Whole of government

systems thinking

Bending the cost curve

Contribution to economic growth

through innovation

Most effective mix of clinical

services delivered

Finding the balance

Applying the full extent of the

NHC mandate

Leading & influencing

sector change

Identify / Prioritise / Advise /

Recommend

Implement Monitor / Evaluate

Innovate

Model of care approach – integrated prioritisation across the continuum of clinical and business decision making

Intervention Level Prioritising the best mix of clinical services to meet current & future need

and maximise health outcomes

Improved patient & population

outcomes

Whole of Government Outcomes Improved population health

& wellbeing

Better Public Services

Improved economic growth

for NZ

Sector Priorities Clinical Leadership

Financial sustainability

Integration Health Targets

FOUR YEAR STRATEGIC PLAN

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National Health Committee 2015

MULTI CRITERIA DECISION MAKING METHODOLOGIES MEGA ANALYSIS

Specific Weighted Outcomes Clinical safety and effectiveness Health and independence gain Materiality Feasibility of adoption Policy congruence Equity Acceptability Cost effectiveness Affordability Risk

Evidence: level of certainty / assumptions / risk HighModerateLowVery low

Dynamic!Systems!

Medium to long term horizon!

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TOOLS - TIERED BUSINESS CASES

Source: NHC Strategic Business Plan 2015/16–2018/19

CLINICAL ADVICE & ENGAGEMENT SECTOR ADVICE & ENGAGEMENT NHC PRIORITY AREAS

Tier 1: Strategic OverviewOutputs:Committee recommendations for T2Published document

Tier 2: Sub-Area AnalysesOutputs:Committee recommendations for T3

Tier 3: AssessmentsOutputs:Assessment reports

Outputs:Published recommendations Supporting assessment reports

Outputs:Recommendations to Minister of Health Supporting documentation

College/Society nominations of key investment / reprioritisation opportunities

ADVICE

ENGAGEMENT

College/Society membership to gain support / approval

NHC presentation to Clinical Leaders on:- Indicative priority sub-areas- Sector Working Group membership- 'Choosing Wisely' input

Production and Dissemination of Information to Clinicians and Patients

Health Sector Forum, DHB CEOs and Chairs through NPRG

Colleges and Speciality SocietiesProgramme Budget, Models of Care &

Surveillance

SECTOR IMPLEMENTATION

NHC MonitoringNHC Evaluation

(as required)

Committee RecommendationFormulation

Committee RecommendationFormulation

Priority Area

Recommendationsto Minister

More detailed analysis

Advisory and Working Groups

Implementationand Analysis

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NATIONAL HEALTH COMMITTEE AND CALLAGHAN INNOVATION WORKING TOGETHER

• NHC’s forecasts

• Priority setting

• Planning• Care

Models• Business

problem

5-15 years

Needs

Identification

• Sounding board

• Solutions considered

• Engage research community

3-10 years

Ideation &

Research

• Develop and apply “disruptive” technologies

• CI grants

2-5 years

Commercial

Vehicles

• Generate evidence

• Watching brief

2-5 years

Clinical Trials

• NHC Innovation Funding

•1-3 years

DHB Case for Change(Fiel

d Trials)

• Sector adoption

• Product development for global market

0-ongoing

Market

Penetration

Making the commercialisation of medical technologies and services easier - and at the same time improving health system outcomes

National Health CommitteeCallaghan Innovation

How do we strengthen this process so that it contributes more effectively to the health system’s continuing capacity to deliver the health outcomes New Zealanders expect - despite emerging pressures and tight fiscal realities - through the adoption of right-headed innovations?

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