New Zealand Respiratory Conference 2014

New Zealand Respiratory Conference 2014

NHC 2014

Marty de Boer

DISCLOSURES

NHC 2014

NATIONAL HEALTH COMMITTEE

Section 11 Advisory Committee responsible for providing the Minister of Health with independent, evidence based recommendations on:Which technologies should be publicly funded in New Zealand

To what level and where technology should be provided

How new technology should be introduced and old technology removed

NHC 2014

WHAT ARE WE TRYING TO ACHIEVE?

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

Evidence based value for money Sustainability Enhanced health contribution to GDP growth

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 APPROACH …

Evidence based, management of non-drug technologies with a focus on models of care

Four domainsClinical safety and effectivenessSocietal and ethicalEconomicFeasibility of adoption

11 decision making criteria

A4R framework

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MODEL OF CARE

Components Pathway of care for 80% of target patient

population Business model that supports and manages the

resource critical nodes in the pathway of care

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Proactive

Reactive

Pull model

Sector Programme Budget

Tiered business cases

Notional Budget

Sector annual referral round

Innovation fund, HRC &CI

Streams

Tools

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Technology management streams and tools

THEN AND NOW

• EGFR• Catheter Ablation

Learning Projects

• 26 Referrals

• Cardiac Cluster

Sector Referrals

• COPD• IHD

Tiered Approac

h

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PROGRAMME BUDGET2013 NHC ANALYSIS OF 2010–2013 NMDS

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

Mean % Price % ($1000s)

Individuals % (n, thousands)

Proactive

• 14/15 Musculoskeletal and Eye

• 15/16 Neoplastics and Endocrine

• 16/17 Hepatobiliary and Kidney and Urinary

• 17/18 Digestive and Mental Health

Reactive referrals

• Age Related Macular Degeneration

• Chronic Lower Back Pain

• Intra Operative Radio Therapy

Pull model

• Diagnostics, genetic testing for bladder cancer

Four year Strategic Work Programme

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NHC Tiered Business Approach to Work PlansSector Engagement and Participation

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

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National Prioritisation Network‘working together for patients and communities’

Purpose to provide the NHC with direction, data, support and a regional perspective that enables wise and effective• prioritisation• implementation• monitoring

NHC NOTIONAL BUDGET MANAGEMENT

1. Direct (Vote: Health) vs Indirect (Whole of Govt)

2. Cost avoided (‘notional’ savings)

3. Released value (‘real’ savings)• cost effectiveness• efficiencies• reprioritisation

4. Evidence based investment (expenditure)

5. Movement of funds between spends

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Example of a notional budget

Source: NHC Executive Notional Budget paper 2014 NHC 2014

• $265m public casemix hospital discharges

• 10 disease states

• Assess prevalence, incidence, health outcomes, health utilisation and cost

• Identify the disease state for Tier 2 assessment with the aim of improving health outcomes whilst maintaining or reducing costs through the prioritisation and application of the most cost effective new and existing health technologies across a model of care

TIER 1 STRATEGIC OVERVIEWRESPIRATORY DISEASE IN NEW ZEALAND

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Advisory Group

Respiratory Physician

DHB P & F

DHB COO

Respiratory Nurse

Specialist

Physiotherapist

Psychologist

General Practitioner

PHO Representativ

e

Patient Representativ

e

Ambulance

Pharmacist

Thoracic Surgeon

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Respiratory Working Group

Source: NHC Executive analysis 2013NHC 2014

Source: 2013 NHC Executive Analysis of 2009/10–2011/2012 NMDS

Burden of Respiratory Disease

Source: NZBDS 2013

DALY Breakdown by Percentage Death Breakdown by Percentage

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Source: 2013 NHC Executive analysis of 2010–2011/12 NMDS and 2010 National Mortality Collection

Burden of Respiratory Disease

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Total price ($ M)

Mean price ($ k)

Individuals (n)

Mean growth (%)

Discharges (n)

30-day acute remission (%)

2010 mortality (n)

2010 years of life lost (YLL)

Time in care (years)

Tuberculosis 2 14.1 150 -19.5 185 16.8 17 261 7

Obstructive sleep apnoea 3 4.5 721 0.3 736 0.8 11 328 4

ILD/sarcoidosis 3 8.7 352 6.1 454 12.6 156 2,110 7

Pulmonary artery disease 4 3.3 1,273 -0.8 1,421 7.6 39 730 10

Bronchiectasis 5 7.3 682 4.5 1,065 17.4 94 1,560 16

Cystic fibrosis 6 28.1 229 0.4 568 14.1 8 421 15

Lung cancer 13 9.3 1,401 -2.7 1,908 15.3 1,622 29,828 27

Asthma 17 2.5 6,619 -5.7 8,403 9.6 57 1,625 34

Other respiratory disorders 45 4.4 10,190 2.9 11,089 6.1 82 878 68

COPD 54 7 7,716 1.5 11,619 17.9 1,588 20,121 134

Lower respiratory tract infection / influenza

112 4.7 24,092 -0.9 28,261 9.3 554 5,537 270

Total 265 5.2 50,664 -0.3 65,709 10.6 4,228 63,397 592

Incident DiseasesEfficiency Gains Required to Reach $5 million

2013 NHC Executive Analysis of 2011/12 NMDSNHC 2014

Source; NCH Decision Making Paper 2013

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Tier 2 COPD: A Pathway to Prioritisation

Source: OECD Data 2011

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Patient numbers and costs along the pathway

Early Stable62%

Minor 29%

Late Stable3%

Moderate-Severe 3%

End-Stage2%

Patients

Early Stable25%

Minor 21%

Late Stable7%

Moderate-Severe 33%

End-Stage14%

Costs

NHC 2014Source: National Health Committee Executive analysis (2013) of 2010/11 New Zealand Health Tracker

Early

Stable

Mino

r

Late

Sta

ble

Mod

erat

e-Sev

ere

End-S

tage

0

1000

2000

3000

4000

5000

6000

7000

8000

9000

Low Dep

Moderate Dep

High Dep

Disease State

$/P

atie

nt

High Dep Moderate Dep Low Dep0

200

400

600

800

1,000

1,200

Māori Average Cost non-Māori Average Cost

Deprivation

$/P

atie

nt

Early Stable Minor Late StableModerate-Severe End-Stage0

1000

2000

3000

4000

5000

6000

7000

8000

Māori non-Māori

Disease State

$/P

atie

nt

Source: National Health Committee Executive analysis (2013) of 2010/11

New Zealand Health Tracker data

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Deprivation and Ethnicity

DHB non admitted ED rate and hospital dischargevariation per 100 for Maori high-deprivation COPD patients

Source :2013 NHC analysis of 2010/11 New Zealand Health Tracker data NHC 2014

NHC Model of Care for COPD 2013NHC 2014

Tier 3 Assessments• Improved diagnosis / case finding• Pulmonary rehabilitation• Long term oxygen therapy• Non invasive ventilation• Advanced care planning

Strategies to reduce ED presentations, admissions and inpatient costs

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HIP ‘bottom up’ research $1.4m

NHC Innovation Fund

LTOT Pulmonary Rehab

NIV

Spirometry ACP

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NHC 2014

Auckla

nd

Bay o

f Plen

ty*

Cante

rbur

y

Capita

l and

Coa

st

Count

ies M

anuk

au*

Hawke

s Bay Hut

t

Lake

s*

Midc

entra

l

Nelson

Mar

lboro

ugh*

North

land

South

Can

terb

ury*

South

ern

Tairaw

hiti

Taran

aki

Waik

ato

Wair

arap

a

Wait

emat

a*

Wes

t Coa

st

Wha

ngan

ui

Total

NZ

0

20

40

60

80

100

120

2006

DHB

CO

PD

LT

OT

/100

K P

op

ula

tio

n

Source: NHC Executive Analysis of Garrett J, Chen B, Taylor DR. A Survey of Respiratory and Sleep Services in New Zealand Undertaken by the Thoracic Society of Australia and New Zealand (TSANZ). The New Zealand Medical Journal. 2009;122(1289).

Long Term Oxygen Therapy

NHC 2014

Auckla

nd

Bay o

f Plen

ty*

Cante

rbur

y

Capita

l and

Coa

st

Count

ies M

anuk

au*

Lake

s*

Midc

entra

l

Nelson

Mar

lboro

ugh*

South

Can

terb

ury*

South

ern

Tairaw

hiti

Taran

aki

Wait

emat

a*

Wha

ngan

ui

Total

NZ

0.00%

0.20%

0.40%

0.60%

0.80%

1.00%

1.20%

1.40%

Current Rate

DHB

Per

cen

tag

e o

f C

OP

D P

atie

nts

Source: NHC Executive Analysis of DHB Oxygen Questionnaire Data, 2014

NHC 2014

Auckla

nd

Bay o

f Plen

ty*

Cante

rbur

y

Capita

l and

Coa

st

Count

ies M

anuk

au*

Hawke

s Bay Hut

t

Lake

s*

Midc

entra

l

Nelson

Mar

lboro

ugh*

North

land

South

Can

terb

ury*

South

ern

Tairaw

hiti

Taran

aki

Waik

ato

Wair

arap

a

Wait

emat

a*

Wes

t Coa

st

Wha

ngan

ui

Total

NZ

0

20

40

60

80

100

120

Current

2006

DHB

CO

PD

LT

OT

/100

K P

op

ula

tio

n

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Further QuestionsWhat does

an appropriate LTOT rate look like?

What is the possible health gain?

What about

portable oxygen?

Less overall variation

Most DHBs follow TSANZ or MoH

guidelines

Data kept inconsistent across DHBsX

NHC 2014

Thank you

www.nhc.health.govt.nz

[email protected]