Economic sustainability of healthcare systems and role of HTA. News from Europe! Journal Club – HEMA Alumni Kellogg School of Management Northwestern University Giuseppe Turchetti, PhD Scuola Superiore Sant’Anna – PISA (Italy) Fulbright Scholar at Kellogg School of Management Evanston, June

The Italian health care system The economic sustainability of the system The role of Health Technology Assessment Prospective evolution and open issues Key points of the presentation

The Italian health care system The economic sustainability of the system The role of Health Technology Assessment Prospective evolution and open issues Key points of the presentation

The World Health Organisation (WHO) in World Health Report 2000 ranked the Italian health care system second among 191 countries. The Italian Health Care System

World Health Report

The National Health Service (NHS) was established in The NHS combines public financing with a mixture of public and private provision. The system aimed to grant universal access to a uniform level of care throughout the country, financed by general taxation. The NHS was created to achieve the objective in article 32 of the Italian Constitution, which declares that the Italian State has the responsibility of safeguarding the health of each citizen as an individual asset and a community interest. Moreover, article 32 affirms that the Italian State guarantees free care to the indigent. The National Health Service

Source: Ministry of Health of Italy. Human dignity : Every individual must be treated with equal dignity and have equal rights irrespective of personal characteristics and role in society. Health need : Everyone in need has a right to health care, and resources should be allocated with priority given to satisfying the basic needs of the population. Equity : Any individual must have access to the health care system with no differentiation or discrimination among citizens and no barrier at the point of use. Solidarity : Available resources have to be primarily allocated to support groups of people, individuals and certain diseases that are socially, clinically and epidemiologically important. Protection : The individual health has to be protected with appropriate preventive measures and interventions. Effectiveness and appropriateness: Resources must be addressed towards services whose effectiveness is grounded and individuals that might especially benefit from them. Priority should be given to interventions that offer greater efficacy in relation to costs. The individual health has to be protected with appropriate preventive measures and interventions. The National Health Service: Principles

Parliament Government Ministry of Health departments National Health Fund – National Solidarity Fund National budget National Institutes for Scientific Research (IRCCS) A Agency for Regional Health Care Services Central level Regional level Regional health departments Regional health fund Regional agencies for health Regional governments Regional budgets Local level Local health authorities Health districts Hospitals Health Promotion divisions Public hospital trusts Private accredited hospitals Citizens Patients Services Co-payment Other programmes A National bodies (technical support to the Ministry of Health) National Institute of Health National Health Council National Institute of Occupational Safety and Prevention Administration and planning Policy and legislation Main financial flow (citizens-NHS/ regional health services)

The central level  National bodies (technical support to the Ministry of Health)  National Institute of Health  National Health Council  National Institute of Occupational Safety and Prevention Parliament Government Ministry of Health departments National budget National Institutes for Scientific Research (IRCCS) Agency for Regional Health Care Services Citizens Patients Other programmes Administration and planning Policy and legislation Main financial flow (citizens-NHS/ regional health services) The Ministry of Health is the main central institution. It manages the National Health Fund and it ensures five different functions, through its department and services: 1.health care planning; 2.health care financing; 3.framework regulation; 4.monitoring; 5.general governance of the National Institutes for Scientific Research (IRCCS). National Health Fund – National Solidarity Fund

The regional level Administration and planning Policy and legislation Main financial flow (citizens-NHS/ regional health services) Regional health departments Regional health fund Regional agencies for health Regional governments Regional budgets Citizens Patients They are responsible for legislative and administrative functions, for planning health care activities, for organizing supply in relation to population needs and for monitoring the quality, appropriateness and efficiency of the services provided. The regional level has: 1.legislative functions; 2.executive functions; 3.technical support and evaluation functions. Regional governments are responsible for pursuing the leading national objectives posed by the National Health Plan at the regional level. Regional health departments are required to guarantee the benefit package to be delivered to the population through a network of population-based health care organizations (local health units) and public and private accredited hospitals.

The local level Local health authorities Health districts Hospitals Health Promotion divisions Public hospital trusts Private accredited hospitals Starting in 1992, a network of public and private health care structures and providers was operating at the local level that can be divided into four different categories:  Local health authorities;  Public hospital trusts;  National Institutes for Scientific Research (IRCCS);  Private accredited providers.

The Italian health care system The economic sustainability of the system The role of Health Technology Assessment Prospective evolution and open issues Key points of the presentation

Source: OECD Health Data 2011; WHO Global Health Expenditure Database OECD countries allocate 9.6% of their GDP to health, ranging from over 17% in the United States to just over 6% in Mexico and Turkey. Indonesia, India and China spend less than 5% of GDP on health

Source: OECD Health Data 2011; WHO Global Health Expenditure Database The share of GDP allocated to health is increasing in all OECD countries, as health spending is growing much faster than GDP

Source: OECD Health Data 2011; WHO Global Health Expenditure Database Annual average growth rate in health expenditure per capita in real terms, (or nearest year) Across OECD countries, health expenditure has grown by 4% annually over the past decade, compared with 1.6% for GDP growth

Which is the return on the investment? Relationship between expense and health indicators Relationship between presence/expense in health technology and health indicators

Life expectancy at in OECD countries Source: OECD Health Data 2011; WHO Global Health Expenditure Database

Health care expenditure has risen considerably over time … Health technology is the first cause!  Technology innovation in medicine is the first cause of the quadruplication of the healthcare expenditure over the period  Less than half of the expenditure can be explained by: increase in moral hazard, higher administrative expenses, and other modifications of the supply and demand mechanism. The other part is caused by health technology innovation.  In USA about two-third (70%) of the medical spending growth and about three-fourth (76%) in the medical spending growth came from cost-increasing advances in medical technology.

Also the level of Health has increased … Life expectancy at birth has increased by 11 years in OECD countries since 1960, reflecting declines in mortality at all ages Source: OECD Health Data 2011; WHO Global Health Expenditure Database Which part of this health improvement is caused by health services and by health technology innovation?

Are technological innovations in medical devices and in medicine financially sustainable? How much health care can we afford? It is new technology that we would look to for cost savings? The sustainability of the system: is it too expensive?

The Italian health care system The economic sustainability of the system The role of Health Technology Assessment Prospective evolution and open issues Key points of the presentation

Health Technology Assessment (HTA) The Health Technology Assessment is a multidisciplinary research area aimed at make “informed” health policy decisions (at the institutional level, individual health organizations and clinical practice) through the assessments of the clinical, economical, ethical, legal and organizational implications regarding the adoption of health technologies. “We shall use the term assessment of a medical technology to denote any process of examining and reporting properties of a medical technology used in health care, such as safety, efficacy, feasibility, and indications for use, cost, and cost effectiveness, as well as social, economic, and ethical consequences, whether intended or unintended.” (Institute of Medicine 1985)

The goal of HTA is to inform the development of safe and effective health policies that are patient focused and seek to achieve best value as defined by decision makers. HTA underpins decisions such as: Should treatment A be reimbursed in a national healthcare system? For which patients should it be provided? For how long should patients receive the treatment? Although the scientific assessment of the available data may be similar wherever the HTA is undertaken, the way in which a technology is appraised (that is, how the assessment is used to devise recommendations on its value in healthcare) may vary from country to country. As a result, different decisions are taken about which technologies should be provided, leading to variation in access to treatments. Health Technology Assessment (HTA)

Technical properties/Specifications : performance, reliability, ease of use and maintenance of technology; Safety : acceptability of risk associated with the use of technology; Efficacy and effectiveness : contribution made by technology to improving the health status of the patient. Efficacy refers to benefits arising from the use of technology in "ideal“ conditions (for example under a clinical trial protocol). Effectiveness considers the benefit derived from the use of a technology under normal conditions; Economic impact : assessment of costs, prices, levels of payment associated with a single technology. The impact is also considered by a macroeconomic point of view (analysis of financing systems and services reimbursement, policies for technological innovation and competitiveness …); Social, legal, ethical and/or political impact: methods applicable for the technologies evaluation are inadequate or nonexistent, but for some technologies can not be irrespective of their consideration. Health Technology Assessment: the evaluation of health technologies

SBU (Swedish Council on Technology Assessment in HC) CCOHTA (Canadian Coodrdinationg Office for Health Technology Assessment) – 1989 (from 2006: Canadian Agency for Drugs and Technology in Health) PBAC (Pharmaceutical Benefits Advisory Committee - Australia) – 1992 IQWiG (Institute for Quality and Efficiency in HC – Germany) NICE (National Institute for Health and Clinical Excellence) EVALUATING VALUE FOR MONEY Relevant HTA experiences

HTA experiences in Europe

HTA experiences in Europe

HTA experiences in Europe

HTA experiences in Europe

HTA experiences in Europe

The Italian health care system The economic sustainability of the system The role of Health Technology Assessment Prospective evolution and open issues Key points of the presentation

Control on HC Technologies Prospective evolution? Reduction of the HC Technology expenses Reduction of HC expense Which implications in term of: Waiting lists Quality of care Diagnostic and therapeutic opportunities Rationing of procedures! Equity of access Future innovation

4 A wider evaluation is necessary!  Organizational impact  Extra hospital costs  Recovery time  Impact on pain and quality of life  Impact on MDs training courses and other involved professionals  Impact on future innovation: technological, organizational and surgical technique  Impact on other disciplines Prospective evolution

How to make the system sustainable? How to increase the health indicators at a national/international level? How to increase the ROI of the investment in HC technology? More technology? Better technology? Better use of technology? Open issues

6 Personal thoughts In which direction should we move?  Creating culture in all stakeholders  Innovation  Sustainability  Appropriateness  Efficiency  Value How? Producing evidences! - Cost-effectiveness studies - Analysis of the cost of the different procedures - HTA studies

Is this our scenario in the near future? Health care costs He has no chances!

We must give answers!

But not this kind of answers...!

….Technology could always help us…. X-RAYS SHOWED A BROKEN RIB, BUT WE ARRANGED WITH PHOTOSHOP

Economic sustainability of healthcare systems and role of HTA. News from Europe! Journal Club – HEMA Alumni Kellogg School of Management Northwestern University Giuseppe Turchetti, PhD Scuola Superiore Sant’Anna – PISA (Italy) Fulbright Scholar at Kellogg School of Management Evanston, June