|Implemented in this survey?|
Disinvestment in health technologies that "are deemed to be not suitable" and reinvesting the resources in other health technologies that meet the criteria of safe, effective and cost-effective care might help to improve the quality and efficiency of care. Unfortunately, experience in the Basque and Galician autonomous regions and in Australia and UK shows that this is a difficult process partly due to the lack of reliable administrative mechanisms to identify and prioritise health technologies.
To facilitate the establishment of an adequate process, in other words: a transparent, systematic and explicit process to assess the potential for disinvestment in certain health technologies or in some of their indications that, whatever the reason is, fail to achieve the objective(s) for which they were originally financed.
The main objectives can be found in the document of reference (Ibargoyen-Roteta et al, 2010, available at http://www.osanet.euskadi.net/osteba/es) and are as follows:
The incentives are related to the obtention of funds for re-investment or investment on innovations of higher added value.
Policymakers, Healthcare managers, Clinicians, biotechnological and pharmaceutical companies, patients
|Degree of Innovation||traditional||innovative|
|Degree of Controversy||consensual||highly controversial|
|Structural or Systemic Impact||marginal||fundamental|
|Public Visibility||very low||very high|
The proposal is rather innovative, because the idea of delisting technologies is not new but the way of facing the problem is innovative. The degree of consensus obtained to establish the process has been high and the the impact both structural and systemic is fundamental. The public visibility could be high if the process is fully established due to the need to inform the different stakeholders, including patients and society and making the process accountable, measurable, credible and specific. Regarding the transferability, this kind of process can be established in any context, but the tool itself defines mechanisms to make tailored interventions rather than "one fits all" ones. The Health system and its characteristics will define the role of each stakeholder in the process, although guidance on how to proceed is suggested.
This new policy has been included in an overall process for the introduction and withdrawal of health technologies in the Basque region and will be included in a similar process for the definition of a common health package in the Spanish Health System.
At the Spanish context and especially in the case of Galician and Basque Autonomous regions, legislative mechanisms were already in place, both for the introduction of new and emerging technologies and for considering the withdrawal of superseded technologies. Nonetheless, practical mechanisms and tools similar to those established for new technologies had to be established for the withdrawal of technologies.
The current policy is in line with the actions that have been defined for the sustainability of the Basque-Spanish Health Systems. It is an opportunity for obtaining funds for innovation and a way to make the process more transparent and accountable.
|Implemented in this survey?|
The idea has been a common approach by different Health Technology Assessment agencies and academia, principally from Spain, Australia and the UK. The main purpose of the idea is to include in the health care system only those technologies of proven added value. There have been different approaches. In Spain, a methodological guideline for the assessment of obsolete health technologies has been developed by the Galician Agency Avalia-t. Osteba, the Basque Office for HTA, has developed a guideline for structuring the decision-making process when a technology has a potential for being withdrawn or delisted from the benefit package or the provision. This Basque guideline has been introduced in the overall process of introduction of new and emerging technologies in the Basque Health System. It will help in a previously established regulatory law for the management of health technologies in the common benefit package.
The approach of the idea is described as:
new: Although the concept of obsolete technology was defined some years ago, no reliable mechanisms were established to delist technologies and inform health managers, clinicians and society on the implications of these mechanisms.
Local level - There is an established program for the introduction of a Guideline for not Funding Technologies (GuNFT guideline) and a software in the Basque Health Service Hospitals.
Within institution - There is an agreement between HTA agencies for the implementation of the process in the Spanish Health System.
Pilot project - A pilot project for testing the Guideline for not Funding Technologies (GuNFT) has been agreed with different hospitals in Spain and the UK (North West region, Manchester).
Other stakeholders and affected groups have started to work in the same field but from the perspective of the identification of technologies of low added value and what the delisting processes could produce in the health systems and the reactions that could be obtained from the establishment of those processes. Similar approaches have been proposed in the case of UK (NICE) and Australia (AHTA).
|MoH and Consumer Affairs of Basque Region||very supportive||strongly opposed|
|Spanish MoH and Social Policy||very supportive||strongly opposed|
|Galician Region MoH||very supportive||strongly opposed|
|Clinic Hospital Innovation Unit||very supportive||strongly opposed|
|Valme Hospital Quality Unit||very supportive||strongly opposed|
|Virgen del Rocio Hospital Subdirectorate||very supportive||strongly opposed|
|Miguel Servet Hospital Technology Assessment Unit||very supportive||strongly opposed|
|Basque Health Service Provision Managers||very supportive||strongly opposed|
|Eurordis||very supportive||strongly opposed|
|ISG of HTA on patients||very supportive||strongly opposed|
|ISG on disinvestment of HTAi||very supportive||strongly opposed|
|Health Cluster net||very supportive||strongly opposed|
|Adam Elshaug||very supportive||strongly opposed|
|Sarah Gardner||very supportive||strongly opposed|
|Steve Pearson||very supportive||strongly opposed|
|Health Technology providers|
|SorTek and ZaharTek networks of experts||very supportive||strongly opposed|
In the case of the Basque Country the legislation was already in place, but there were no mechanisms to produce the results stated in the legislation. Also, there has been no guidance on how to promote and structure the process and what the role of the different stakeholders should be. In fact, managers and clinicians had no knowledge of the legislation and its implications on the sustainability of the health systems. The idea of "one technology in and one out" was implicit, but no methodological approaches were developed to face the aforementioned process.
|MoH and Consumer Affairs of Basque Region||very strong||none|
|Spanish MoH and Social Policy||very strong||none|
|Galician Region MoH||very strong||none|
|Clinic Hospital Innovation Unit||very strong||none|
|Valme Hospital Quality Unit||very strong||none|
|Virgen del Rocio Hospital Subdirectorate||very strong||none|
|Miguel Servet Hospital Technology Assessment Unit||very strong||none|
|Basque Health Service Provision Managers||very strong||none|
|ISG of HTA on patients||very strong||none|
|ISG on disinvestment of HTAi||very strong||none|
|Health Cluster net||very strong||none|
|Adam Elshaug||very strong||none|
|Sarah Gardner||very strong||none|
|Steve Pearson||very strong||none|
|Health Technology providers|
|SorTek and ZaharTek networks of experts||very strong||none|
The successful implementation of the framework described in this proposal depends, in turn, on a number of different factors that must be taken into consideration:
Mechanisms have been established to evaluate the implementation process; nevertheless, the policy has been recently established and no accountable results have been obtained. The indicators are related to the:
The mid term review and final internal evaluations will be accomplished at least in the case of the Basque and Galician Autonomous Regions. Further developments have to be agreed at the Spanish level.
Mid-term review or evaluation, Final evaluation (internal)
Structure, Process, Outcome
None at the moment.
Some possible unintended side-effects could be: excessively bureaucratic mechanisms of control, no information provided to stakeholders or a way to delist technologies with doubtful value but producing a gap on health care provision. Other undesirable effects could be related to no accountable, transparent and systematic mechanisms, a lack of learning capacities in some organizations that provide health care or no mechanisms or incentives to those involved in the process.
|Quality of Health Care Services||marginal||fundamental|
|Level of Equity||system less equitable||system more equitable|
|Cost Efficiency||very low||very high|
The impact of this policy could be high because it takes into account the opinions of different stakeholders, proposes a transparent process to delist health technologies and offers a more sustainable way of managing health technologies by considering not only the introduction of innvovation but the withdrawal of technologies of low added value that permits the re-allocation of resources and more active policies of innovation while maintaing the know-how of professionals.
Iñaki Gutiérrez Ibarluzea; Nora Ibargoyen Roteta; Gaizka Benguria Arrate; Lorea Galnares Cordero; José Asua Batarrita;
Osteba, Basque Office for Health Technology Assessment