HTA – Algorithm or Process?; Comment on “Expanded HTA: Enhancing Fairness and Legitimacy”

Document Type: Commentary

Author

Department of Economics & Related Studies and Centre for Health Economics, University of York, York, UK

Abstract

Daniels, Porteny and Urrutia et al make a good case for the idea that that public decisions ought to be made not only “in the light of” evidence but also “on the basis of” budget impact, financial protection and equity. Health technology assessment (HTA) should, they say, be accordingly expanded to consider matters additional to safety and cost-effectiveness. They also complain that most HTA reports fail to develop ethical arguments and generally do not even mention ethical issues. This comment argues that some of these defects are more apparent than real and are not inherent in HTA – as distinct from being common characteristics found in poorly conducted HTAs. More generally, HTA does not need “extension” since (1) ethical issues are already embedded in HTA processes, not least in their scoping phases, and (2) HTA processes are already sufficiently flexible to accommodate evidence about a wide range of factors, and will not need fundamental change in order to accommodate the new forms of decision-relevant evidence about distributional impact and financial protection that are now starting to emerge. HTA and related techniques are there to support decision-makers who have authority to make decisions. Analysts like us are there to support and advise them (and not to assume the responsibilities for which they, and not we, are accountable). The required quality in HTA then becomes its effectiveness as a means of addressing the issues of concern to decisionmakers. What is also required is adherence by competent analysts to a standard template of good analytical practice. The competencies include not merely those of the usual disciplines (particularly biostatistics, cognitive psychology, health economics, epidemiology, and ethics) but also the imaginative and interpersonal skills for exploring the “real” question behind the decision-maker’s brief (actual or postulated) and eliciting the social values that necessarily pervade the entire analysis. The product of such exploration defines the authoritative scope of an HTA.

Keywords

Main Subjects


"Watch the Video Summary"

 

  1. Office of Technology Assessment. Development of Medical Technology: Opportunities for Assessment. Washington DC: US Government Printing Office; 1976.
  2. Banta D. The development of health technology assessment. Health Policy. 2003;63:121-132.
  3. Daniels N, Porteny T, Urrutia J [correction of Urritia J]. Expanded HTA: enhancing fairness and legitimacy [published correction appears in Int J Health Policy Manag. 2016;5(5):347]. Int J Health Policy Manag.2016;5(1):1–3. doi:10.15171/ijhpm.2015.187
  4. Culyer AJ, Podhisita C, Santatiwongchai B. A Star in the East: A Short History of HITAP. Bangkok: Health Intervention and Technology Assessment Program; 2016.
  5. Culyer AJ. The Dictionary of Health Economics. 3rd ed. Cheltenham: Edward Elgar; 2014.
  6. Hoffman BM. Toward a procedure for integrating moral issues in health technology assessment. Int J Technol Assess Health Care. 2005;21(3):312-318.
  7. Hofmann BM. Why ethics should be part of health technology assessment. Int J Technol Assess Health Care. 2008;24:423-429. doi:10.1017/S0266462308080550
  8. Hoffman BM. Why not integrate ethics in HTA: identification and assessment of the reasons. GMS Health Technol Assess. 2014;10:Doc04. doi:10.3205/hta000120.
  9. Daniels N, Sabin J. The ethics of accountability in managed care reform. Health Affairs. 1998;17:50-64.
  10. Brouwer WB, Culyer AJ, Job N, van Exel A, Rutten FF. Welfarism vs. extra-welfarism. J Health Econ. 2008; 27: 325–338. Reprinted in Cookson R, Claxton K, eds. The Humble Economist: Tony Culyer on Health, Health Care and Social Decision Making. London: Office of Health Economics; 2012:67-78.
  11. Gold MR, Siegel JE, Russell LB, Weinstein MC, eds. Cost-effectiveness in Health and Medicine. New York: Oxford University Press; 1996.
  12. National Institute for Health and Care Excellence. Guide to the Methods of Technology Appraisal. London: NICE; 2013.
  13. Bill and Melinda Gates Foundation Methods for Economic Evaluation Project (MEEP). Final Report and Appendices.London: NICE; 2014.
  14. Bill and Melinda Gates Foundation Methods for Economic Evaluation Project (MEEP). The Gates Reference Case: What it is, why it's important, and how to use it. London: NICE; 2014.
  15. Culyer AJ. Are there really ten good arguments for a societal perspective in the economic evaluations of medical innovations? In: Culyer AJ, Kobelt G, eds. Portrait of a Health Economist: Festschrift in Honour of Bengt Jönsson. Lund: Institute of Health Economics; 2014:33-38.
  16. Culyer AJ, Bombard Y. An equity framework for health technology assessments. Med Dec Making. 2012;32:428-441.
  17. Norheim OF, Baltussen R, Johri M, et al. Guidance on priority setting in health care (GPS-Health): the inclusion of equity criteria not captured by cost-effectiveness analysis. Cost Eff Resour Alloc. 2014;12:18. doi:10.1186/1478-7547-12-18
  18. Johri M, Norheim OF. Can cost-effectiveness analysis integrate concerns for equity? Systematic review. Int J Technol Assess Health Care. 2012;28(2):125-132. doi:10.1017/S0266462312000050
  19. Cookson R, Drummond M, Weatherly H. Explicit incorporation of equity considerations into economic evaluation of public health interventions. Health Econ Policy Law. 2009;4(Pt 2):231-245. doi:10.1017/S1744133109004903
  20. Wailoo A, Tsuchiya A, McCabe C. Weighting must wait: incorporating equity concerns into cost effectiveness analysis may take longer than expected. Pharmacoeconomics. 2009;27:983-989.
  21. Epstein DM, Chalabi Z, Claxton K, Sculpher M. Efficiency, equity, and budgetary policies: informing decisions using mathematical programming. Med Dec Making. 2007;27:128-137.
  22. Baltussen R, Niessen L. Priority setting of health interventions: the need for multi-criteria decision analysis. Cost Eff Res Alloc. 2006;4:4.
  23. Culyer AJ, Lomas J. Deliberative processes and evidence-informed decision-making in health care – do they work and how might we know? Evidence and Policy. 2006;2:357-371. (Reprinted in Cookson R, Claxton K, eds. The Humble Economist: Tony Culyer on Health, Health Care and Social Decision Making. London: Office of Health Economics; 2012: 283-300).
  24. Culyer AJ. Deliberative Processes in Decisions about Health Care Technologies: Combining Different Types of Evidence, Values, Algorithms and People. London: Office of Health Economics; 2009.
  25. Asaria M, Griffin S, Cookson RA, Whyte S, Tappenden P. Distributional cost-effectiveness analysis of health care programmes: A methodological case study of the UK bowel cancer screening programme. Health Econ. 2015;24:742-754.
  26. Robson M, Asaria M, Tsuchiya A, Ali S, Cookson R A. Eliciting the level of health inequality aversion in England (CHE Research Paper no. 125). York: Centre for Health Economics, University of York; 2016.
  27. Verguet S, Laxminarayan R, Jamison DT. Universal public Finance of tuberculosis treatment in India: an extended cost‐effectiveness analysis. Health Econ. 2015;24:318-332.
  28. Culyer AJ. Equity and Equality, in Henk ten Have ed. International Encyclopaedia in Global Bioethics. Berlin: Springer; 2016. http://link.springer.com/referenceworkentry/10.1007/978-3-319-05544-2_176-1. Accessed  April 8, 2016.
  29. Culyer AJ. The bogus conflict between efficiency and equity. Health Econ. 2006;15:1155-1158.
  30. Culyer AJ, Wagstaff A. Equity and equality in health and health care. J Health Econ. 1993;12:431-457. (reprinted in Barr N, ed. Economic Theory and the Welfare State, Cheltenham: Edward Elgar; 2001:231-257 and in Culyer AJ, ed. Health Economics: Critical Perspectives on the World Economy. London: Routledge; 2006:483-509).