Battle for the best Health Technology Assessment processes

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A government review of the Health Technology Assessment (HTA) processes is underway, and various aspects of the latest options paper proposing changes to the system that decides government funding has not been warmly received by all respondents.

The HTA processes involve a panel of medical experts that evaluate what health technologies — particularly new medications — should be sold and funded by government under four programs. Those are the Pharmaceutical Benefits Scheme, the Medicare Benefits Schedule, the National Immunisation Program and the Life Saving Drugs Program.

Paul Cross, a former adviser to two health ministers, says Australia was the first in the world to legislate a process for evaluating health technologies — it kicked off in 1993 — and it has what was a fairly neutral objective.

“It is a process that is used to determine whether the government should pay for a new medicine and how much it should pay for it compared to what it is currently paying for,” Cross says.

“You do get exceptional circumstances where a new technology, a new medicine comes to market and the government is not paying anything for an existing treatment because there are no existing treatments.

“It doesn’t happen a lot, but it probably happens once a year or once every couple of years and it presents the system with unique challenges.”

Cross says there was at one point an emergence of a range of new medicines that needed an evaluation process so that data about new drugs could be assessed so the decision about whether something new could replace something old.

The HTA also has its quirks because some therapies, such as one-off and gene therapies, are not assessed for the purposes of the PBS but are seen as ‘medical technologies’ funded separately.

A 182-page discussion paper released earlier this year set out options for process improvements, but it has been roundly criticised by Medicines Australia, an organisation with which the federal government has a strategic agreement.

The Medicines Australia submission supports the general objectives of improving the HTA and getting medications into the hands of people earlier, but it is opposed to a range of suggestions such as trying to incentivise lower prices that will create problems with competition.

Reform of the system might be necessary to bring the system up to date, Medicines Australia’s submission says, but there are parts of the system that remain useful. 

“It is important to emphasise that there are many features of the current system that are working well and should be retained (and in some cases enhanced) including: special pricing arrangements and confidential pricing, indication-based pricing, parallel processing, defined timelines, the PBS process improvements, flexibility in decision making, transparency of process, the TGA reforms, patient and prescriber choice, and deeds of agreement,” Medicines Australia wrote.

Other submissions reflected a range of concerns that related to the needs of practitioners as well as those of consumers that are ultimately the focus of the HTA processes.

The Royal Australian College of General Practitioners (RACGP) has asked that general practitioners be involved in consultations when the government is considering dropping funding for certain therapies so that the impact on prescribers and their patients can be properly considered.

A submission from the peak body of GPs emphasised that most Australians use their doctors as the first port of call for medical treatment. GPs prescribe, educate and counsel patients on medication use, and deprescribe when appropriate.

The RACGP said decisions to remove funding for certain recommendations would benefit from the holistic perspective that GPs have to patient care.

“In cases where funding for a previously supported product is restricted or removed, GPs should be provided with advance notice, a clear explanation, and an opportunity to contribute to the decision-making process,” the RACGP submission says.

“This not only ensures transparency but also allows GPs to provide valuable input and make necessary prescribing changes, especially considering that some GP prescribing occurs at intervals of 6-12 months for patients whose condition is stable.

“Including input from GPs, as specialist generalists, into evidence-to-decision frameworks helps prevent an excessive focus on a single organ system and narrow outcomes.”

Consumer groups such as Asthma Australia and the Consumers Health Forum commented on the communication and transparency of the HTA regime, responding to the options paper with suggestions that documentation be made jargon-free.

Asthma Australia, for example, characterised existing communication as “inadequate, inappropriate, and inconsistently applied across different HTA processes” and the language in most communications is inaccessible to many users forced to use a website that is difficult to navigate.

“The health literacy of consumer populations varies widely and information will need to be tailored to make it as accessible and informative as possible to enable engagement into HTA processes,” Asthma Australia says. 

“This can be challenging and may require several different versions of the same information.”

Doctors for the Environment Australia (DEA) responded to the options paper by welcoming the drift toward the use of environmental impacts as part of the mix when health technologies are being evaluated.

“The HTA review is an opportunity for all reimbursement decisions to be expanded to health outcomes, financial impacts and environmental impacts,” the DEA submission says.

“This triple-bottom-line approach aligns clearly with most businesses and organisations that have adopted environmental, social and corporate governance.”

The DEA submission also says that the healthcare sector must be held accountable for the carbon emissions it creates.

“Healthcare, including in Australia, has a very large carbon footprint (about half that of the entire construction section),” it says.

“Responsibility for cutting healthcare carbon emissions must rest within healthcare and is not the responsibility of other sections of government or the economy.”

The DEA’s submission also argues that government funding of health technologies with an adverse environmental impact is unethical.

“HTA reform is required to prevent Australian government funds subsidising healthcare products with high carbon footprints when a lower carbon footprint product that is clinically acceptable exists,” the submission says.

“Such high carbon subsidisation indirectly leads to detrimental effects on the health of Australians, Australia’s healthcare system’s delivery of health care and to economic loss and damage.”

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