Health technology assessment in Spain

The Spanish Constitution of 1978 established a healthcare system available to everyone and free at the point of service. The General Health Law of 1986 also established the framework for a National Health System (NHS). The Constitution and the law form the regulatory framework for the devolution of healthcare services to the Autonomous Regions. All the 17 Autonomous Regions have complete power regarding public health and planning. However, responsibilities on healthcare financing, organization, provision, and management have devolved to only seven Autonomous Regions. Financial support for health services comes mostly from taxes. Global budgets are a mechanism used by hospitals to control the acquisition of medium and low health technology. Major capital investments for health technology are controlled by the central government in 10 Autonomous Regions (population coverage of 38%) and by the Regional Health Services in the seven remaining Autonomous Regions. In 1995 a regulation for basing the introduction of new procedures and medical equipment on the assessment of safety, efficacy, and efficiency was issued. Health technology assessment (HTA) has a long history in Spain, beginning with the Advisory Board on High Technology in the government of Catalonia in 1984. This board evolved into the Catalan Agency for HTA (CAHTA) in 1994. The Basque Country established a unit for HTA in 1992 (Osteba) and the Andalusian government created an agency in 1996 (AETSA). A national agency for HTA (AETS) was established in 1994. These different programs coordinate their work and together act as an Advisory Committee of the Interregional Council of the NHS.     

Agency problems of global budget system in Taiwan's National Health Insurance

The main purpose of this study was to investigate the agency problem presented by the global budget system followed by hospitals in Taiwan. In this study, we examine empirically the interaction between the principal: Bureau of National Health Insurance (BNHI) and agency: medical service providers (hospitals); we also describe actual medical service provider and hospital governance conditions from a agency theory perspective. This study identified a positive correlation between aversion to agency hazard (self-interest behavior, asymmetric information, and risk hedging) and agency problem risks (disregard of medical ethics, pursuit of extra-contract profit, disregard of professionalism, and cost orientation). Agency costs refer to BNHI auditing and monitoring expenditures used to prevent hospitals from deviating from NHI policy goals. This study also found agency costs negatively moderate the relationship between agency hazards and agency problems     

The improvement of the animal health risk analysis system in France

After several decades of gradual improvement in its system for managing health risks, France was confronted in 1996 with the bovine spongiform encephalopathy crisis. This triggered a collective questioning, which highlighted the need to reform a system that had shown its limitations. Risk analysis, established as a key principle by the Agreement on the Application of Sanitary and Phytosanitary Measures (SPS Agreement) of the World Trade Organization (WTO), was cast as the necessary basis of the reform, objectives of which were to better identify priority risks in order to ensure the protection of human and animal health, and to improve the quality of measures implemented by the public authorities. The Act of 1 July 1998 founded several independent risk assessment agencies, including the French Agency for Food Safety (AFSSA), with the specific mandate of food safety at every stage of the food chain. Other organisational reforms enhanced the new system, notably the separation between the functions of risk management and economic support for food industries, initially at central level, then in 2002 at the level of field services in the 100 French départements. Lastly, new procedures were introduced. These were designed, in accordance with the principles of risk assessment, to better identify and to individualise the different decision-making sequences. The decision-making process was extended to include submission to the agency in charge of evaluating health risks and examination by the agency of the resulting draft decision.     

Linking evidence from health technology assessments to policy and decision making: the Alberta model

OBJECTIVES: The objective of this study was to develop and implement a decision-making process for public funding of health services that links policy areas with health technology assessment and input from interested parties. METHODS: Health authorities, assessment organizations, and healthcare professionals were consulted as a follow-up to recommendations of an expert panel established by the Alberta government. The methods involved formulation of an eight-stage, collaborative process that incorporates identification through the health ministry of health technologies requiring review, assessment of the technologies using expert groups in Alberta, and consultation and formulation of advice within the ministry to inform ministerial funding decisions. RESULTS: All components of the decision process have been put in place and have collaborated to provide advice to inform policy on provincial health services. Of nineteen technologies selected for review, five have been completed and decisions made: laparoscopic adjustable gastric banding, fetal fibronectin assay for premature labor, newborn screening for cystic fibrosis, newborn screening for inborn errors of metabolism, and gastric electrical stimulation. A further six reviews are in progress, and reviews of the remaining technologies are planned for 2007. CONCLUSIONS: Bridging the evidence-to-policy gap is more likely to succeed when the policy community is actively engaged and an explicit model is used to put health technology assessment into practice.     

澳大利亚政府对公立医院的以活动为基础的筹资付费方式与启示

基于卫生制度改革的需要,澳大利亚在全国范围内推行以活动为基础的筹资(activity based funding,ABF)付费方式,并于2011年设立独立医院定价管理局作为具体执行机构。ABF付费方式的主要内容包括医疗服务定价、医疗服务分类、临床数据收集和服务成本核算。该方式对我国公立医院资金拨付过程中的支付方式顶层设...     

Health technology assessment in Ireland

Ireland's health system is primarily funded from general taxation and is publicly provided, although private health care retains a considerable role. It is a unique structure, a mixture of universal health service free at the point of consumption and a fee-based private system where individuals subscribe to private health insurance that covers some of their medical expenses. The recent history of the Irish health services saw consolidation of existing services and an expansion into new areas to adapt to changing practices and needs. There has also been a drive to extract maximum efficiency so as to maintain the volume and quality of patient services at a time of very tight financial constraints. Introduction of new health technologies continued to accelerate. New technologies tended to spread rapidly before systematic appraisal of their costs and benefits. When the state is involved in funding the public hospital system, acceptance of new technology is a matter for discussion between agencies and the Department of Health and Children. Decisions about spending annual "development funding" have generally not been based on careful assessment of proposals for new technology. In 1995, a healthcare reform put new Public Health Departments in Health Boards in a prime position in Ireland's health services organization. These departments now emphasize evidence-based medicine. While Ireland does not have a national health technology assessment (HTA) program, there are plans to form an advisory group on HTA in 1998. HTA is seen as a significant element of future health policy in Ireland.     

Are donor allocations for humanitarian health assistance based on needs assessment data?

Abstract

Donors have agreed to fund humanitarian assistance according to needs. We studied if project applications to a major donor, and the subsequent funding decisions for humanitarian health projects contained needs assessment data.

In 2003, a total of 258 million SEK (37 million USD) was allocated by Swedish International Development Cooperation Agency (Sida) to 38 humanitarian health projects. Only 14 applications (37%) had data on the size of the target population while reference to any quantified health needs was found in less than 30% of the funding decisions. In contrast to stated policy, interviews with staff at Sida revealed that needs assessment data had a limited role in the funding decisions, whereas the implementing capacity of the applying agency was of great importance.

Our findings suggest that needs assessment data has a very limited role in the decision to fund while other, not clearly defined factors are more important.     

Health technology assessment in Portugal

The Portuguese healthcare system is often portrayed as a National Health Service (NHS) model, characterized by universal coverage, comprehensive benefits, nearly free services, national tax financing, and public ownership or control of the factors of production. However, in reality the system fails to accomplish these features in a complete way. There coexist a number of occupation-related health insurance schemes that were originally intended to be integrated into the NHS. In addition, in key areas the NHS does not provide the wide range of services it promises. The public sector has a predominant role in the provision of hospital stays and general practitioner consultations, but the private sector provides a major portion of specialist consultations, dental consultations, and diagnostic services. Major problems in the system led to health reforms in the 1990s. New reform proposals include some specific steps concerning health technology, including standards for medical equipment based on quality, geographic distribution, sustainability, and cost-effectiveness. A new National Plan of Health Equipment was completed in 1998, aimed at improving the distribution of equipment. Despite reforms, healthcare expenditures continue to rise. There is general agreement that gains in efficiency could be made. This situation is beginning to encourage interest in health technology assessment (HTA) in Portugal, although these activities are not yet very developed. Recently, legislation requiring presentation of economic evaluations for new pharmaceutical products was enacted. Present plans also call for the creation in the future of a national agency for HTA.     

The legislative battle over health services research.

Budget reconciliation legislation in 1989 created the new Agency for Health Care Policy and Research (AHCPR), which folded in the National Center for Health Services Research and Health Care Technology Assessment, among the law's other provisions. The creation of the new agency represented a shift in priorities toward outcomes and effectiveness research in medical practice and made explicit the federal government's role in developing practice guidelines. The new agency was born in the midst of an extraordinary bipartisan budget negotiation process in late 1989; its becoming linked to the contentious issue of physician payment reform nearly killed the new agency before it appeared. The narrative of political wrangling that resulted in the creation of AHCPR spans Capitol Hill, the White House, the agencies of the Department of Health and Human Services, and renowed health services researchers on either coast and in Washington, D.C.     

The paradox of non-evidence based,publicly funded complementary alternative medicine in the English National Health Service: An explanation

Despite the unproven effectiveness of many practices that are under the umbrella term ‘complementary alternative medicine’ (CAM), there is provision of CAM within the English National Health Service (NHS). Moreover, although the National Institute for Health and Care Excellence was established to promote scientifically validated medicine in the NHS, the paradox of publicly funded, non-evidence based CAM can be explained as linked with government policy of patient choice and specifically patient treatment choice. Patient choice is useful in the political and policy discourse as it is open to different interpretations and can be justified by policy-makers who rely on the traditional NHS values of equity and universality. Treatment choice finds expression in the policy of personalised healthcare linked with patient responsibilisation which finds resonance in the emphasis CAM places on self-care and self-management. More importantly, however, policy-makers also use patient choice and treatment choice as a policy initiative with the objective of encouraging destabilisation of the entrenched healthcare institutions and practices considered resistant to change. This political strategy of system reform has the unintended, paradoxical consequence of allowing for the emergence of non-evidence based, publicly funded CAM in the NHS. The political and policy discourse of patient choice thus trumps evidence based medicine, with patients that demand access to CAM becoming the unwitting beneficiaries.     

Are the UK Systems of Innovation and Evaluation of Medical Devices Compatible? The Role of NICE’s Medical Technologies Evaluation Programme (MTEP)

The economic evaluation of medical products and services is increasingly prioritised by healthcare decision makers and plays a key role in informing funding allocation decisions. It is well known that there are a number of methodological difficulties in the health technology assessment of medical devices, particularly in the provision of efficacy evidence. By contrasting devices with pharmaceuticals, the way in which the differing systems of innovation mould the UK’s industry landscape is described and substantiated with market statistics. In recognition of the challenges faced by industry, as well as the growing need for cost-effective allocation of National Health Service (NHS) resources, the National Institute for Health and Care Excellence (NICE) led the development of the Medical Technologies Evaluation Programme (MTEP), which launched in 2009/2010. The review of the UK’s medical devices market supports the programme’s three principal aims: to simplify access to evaluation, speed up the process, and increase evaluative capacity for devices within NICE. However, an analysis of the output of MTEP’s first 3 years suggests that it has some way to go to meet each of these aims.     

Die deutsche Agentur für Health Technology Assessment (HTA) beim DIMDI (DAHTA@DIMDI)

With the Health Reform Act 2000 the assessment of medical procedures (Health Technology Assessment, HTA) was first applied to quality assurance in German public health. Since taking this step Germany belongs to the group of countries (Great Britain, Sweden, Australia, etc.) that employ HTA as an objective instrument to determine scientific grounds for political health decisions, for instance for decisions concerning absorption of costs or the development of a benefit catalogue. The German Agency for Health Technology Assessment was founded in September 2000 at the German Institute for Medical Documentation and Information (DAHTA@DIMDI) to fulfil the legal requirements. DAHTA set up and operates a databank-supported information system to supply HTA- relevant information. Additionally research assignments are commissioned for this area and quality standards determined. The goal is to create an up to date and objective information base for health politics and also for medical qualified personnel and consumers that considers the social, ethical, economical and legal results besides the efficacy and effectiveness of medical procedures.     

Local public health agency capacity and its relationship to public health system performance.

he study described in this article identifies local public health agency capacity characteristics that are related to their local public health systems' performance scores on the CDC's National Public Health Performance Standards Program assessment instrument. Public health system performance scores from a test version of the National Public Health Performance Standards instrument (5b) from county and city/county jurisdictions in three states were matched to organizational capacity data from the 1997 National Association of County and City Health Officials profile of health departments, resulting in a sample of 152 jurisdictions. Twenty-eight capacity variables from the profile and all 10 scores on the Essential Public Health Services plus the total performance score were analyzed in 11 separate multivariate regression models. Public health agency capacities in the areas of funding, organizational leadership, and certain nonprovider partnerships were found to be significantly related to public health system performance. Further study is needed to determine if these relationships between agency capacities and system performance are found, with data from other states now using the nationally released performance assessment instruments and with capacity measures that are more specific for evaluating public health system performance.     

构建和谐社会视野下的医疗公正与宏观卫生政策

公正是科学发展观的重要内容,是卫生系统的主要价值取向,实现公正是医药卫生界的神圣职责。自从医疗保健政策向"经济导向型"方向转变之后,国家大幅度减少了对卫生事业的投入,医院必须从病人身上取得卫生发展必要的资金,医药费用上涨是必然的,也就失去了公平和公正。在今后的深化改革中,必须强调医学目的,贯彻以人为本的指导思想,加大政府的投入,围绕公正目标,建立覆盖全民的医疗保障体制。     

Challenges,choices, and Canada

The Canadian Coordinating Office for Health Technology Assessment (CCOHTA) was established by the Federal, Provincial, and Territorial Ministers of Health in 1989 for a 3-year trial period. In 1993 CCOHTA was made a permanent organization and in 1999 the Deputy Ministers of Health renewed CCOHTA's mandate and increased its funding. CCOHTA's role is to coordinate health technology assessment (HTA) priorities across jurisdictions, foster and undertake assessment activity, and function as a clearinghouse for technology assessment results while increasing healthcare system stakeholder awareness of HTA findings. The coordinated and collaborated approach adopted by CCOHTA minimizes duplication with other national and provincial organizations and contributes to the ability of the Canadian healthcare system to continue to deliver high-quality health care to its constituents.     

Health promotion in France. Toward a new way of giving medical care

Health promotion is not a concept often encountered in France, especially in university teaching hospitals. In fact, the spontaneous orientation of healthcare services tends to emphasize high-technology care, rather than preventive care. This article describes the main characteristics of the French healthcare system, some new elements of its health policy, and a specific experiment of health promotion in a new geriatric hospital.     

Introduction of freedom of choice for hospital outpatient care in Portugal: Implications and results of the 2016 reform

In Portugal, the National Health Service (NHS) assures universal access to medical treatment and care that is free at the point of delivery – except for relatively small user charges. Freedom of choice is limited and competition between the public and the private sectors is almost non-existent. In May 2016, the Ministry of Health introduced a new law that facilitates the referral of NHS users from primary healthcare units to outpatient consultations in NHS hospitals outside of the referral area. However, for inpatient care, patients are still bound to receive treatment within their referral area, which is determined by place of residence. The aim of the reform was to provide a timelier response to citizens' health needs and to increase efficiency. According to preliminary data from June 2016 to May 2017, 10.6% of all outpatient referrals from NHS primary health care units were made to an NHS hospital out of the referral area, with the highest proportion in the Lisbon (15.8%) region. In general, median waiting time for first outpatient consultation increased after the introduction of choice in the five specialties with the highest proportions of out-of-area referrals - but it reduced in two departments with the longest waiting times prior to the reform. The reform constitutes a major change to the relationship between NHS hospitals, with foreseeable consequences in hospital funding and the patients' perception of hospital quality.     

Treading Water: The No-Growth Investment in Health Services Research

There is a “perfect storm” brewing in the American healthcare system. Healthcare spending has grown faster than our economy for many years and is projected to double in as little as 10 years. In spite of what we spend on healthcare, research tells us that we only receive appropriate care half the time. We are simply not getting what we are paying for. Health services research provides the data and the evidence needed to make better decisions, design healthcare benefits, and develop effective policies to optimize healthcare financing, facilitate access to healthcare services, and improve healthcare outcomes. Despite what we know and what we can learn from health services research, federal funding for this important field continues to erode. This article provides a primer on the federal budget process and summarizes findings from the Federal Funding for Health Services Research 2007.Health services research (HSR) explores healthcare costs, quality, and access and seeks ways to improve healthcare delivery, safety, availability, and affordability. HSR has been defined as a “multidisciplinary field of scientific investigation that studies how social factors, financing systems, organizational structures and processes, health technologies, and personal behaviors affect access to healthcare, the quality and cost of healthcare, and ultimately our health and well-being.”1 In particular, HSR identifies what treatments work best when, for whom, and at what sites of service; it evaluates how best to finance healthcare and control spending; it helps inform healthcare benefit design; it translates the innovations from basic bench science into medical practice, allowing providers, health plans, and patients to make more informed health choices. HSR is the link between research and patient care.Since 2003, the Coalition for Health Services Research (coalition) has been tracking the federal government''s investment in HSR by collecting budgetary data from federal agencies that principally fund HSR. The coalition has been collecting annual budgetary data from the federal agencies that fund HSR. In the past 5 years, we have found that despite what we can learn from HSR, there has been an erosion of federal funding for this field, in part because of competing federal priorities, a constrained fiscal climate, and polarizing partisan politics. These trends have likely hindered the ability of the researchers to examine the healthcare system and identify innovative and effective solutions. If left unchecked, the declining investment in HSR may have further implications for the study of health and patient care in the future.This article provides a primer on the federal budget process and summarizes findings from Federal Funding for Health Services Research 2007, the fifth annual report of HSR expenditures.2Federal agencies have not developed or adopted a uniform definition for HSR or standard categories for collecting and reporting data about reimbursement and funding methodologies, health disparities, patient safety, and chronic disease management. Therefore, questions remain about the breadth and scope of activities included in the funding totals presented in this article. Investments in what any one agency has self-reported as “health services research” may not be equivalent to what is reported by another agency. For example, budget numbers can reflect entire agency budgets, including overhead costs or a rough estimate of dollars spent on HSR. Nevertheless, our data offer the best available estimate on the federal government''s investment in this area.     

The influence of medical cost controls implemented by Taiwan's national health insurance program on doctor–patient relationships

To prevent medical costs from rising, the National Health Insurance administration implemented the global budget system for financial reform, effective 1 July 2004. Since the implementation of this system, patients have been required to pay for some medicines to limit costs to the system. More recently, as they have faced constant increases in health insurance fees and also faced an increase in the number of medical expenses they must pay during an economic recession and a rise in unemployment, would the economic burden on the people of Taiwan not be increased? Even though National Health Insurance is a form of social insurance, does it guarantee social equality? The value of the healthcare industry is irreplaceable, so the most critical concern is whether worsening doctor–patient relationships will worsen healthcare quality. In short, while the global budget system saves on National Health Insurance costs, whether its implementation has affected healthcare quality is also worth exploring. This commentary also hopes to serve as a reference for the implementation of national health insurance in the United States. Copyright © 2014 John Wiley & Sons, Ltd.     

Decentralising the health sector: issues in Brazil

The health sector in Brazil has undergone important changes, particularly with the development of the Unified Health System (SUS). Decentralisation is an important principle of SUS and advances have been made in transferring responsibilities and resources to the local government units, known as municipios. This article describes the changes introduced, focusing on the system of municipio classification and the funding mechanisms introduced through the basic operating rule (BOR) of 1996. The paper then moves on to analysing three key issues of decentralisation in Brazil that are related to the policy process, the system of decentralisation and the output of decentralisation. Firstly, the formal process by which decisions on health sector reform are made is discussed with particular attention being paid to the negotiated and relatively open policy space. Secondly, the role of the states is discussed within the decentralised system. Thirdly, the impact of decentralisation on equity is discussed with particular reference to the resourcing of the Municipal Health Funds. The article concludes by emphasising the political nature of health sector decentralisation and the need to develop the conditions for effectiveness in decentralisation programmes.