Setting Priorities for Health Technologies Assessment A Model Process (1992) / Chapter Skim
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2 METHODS FOR PRIORITY SETTING
2 METHODS FOR PRIORITY SETTING
Pages 31-49
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From page 31... ...
use the results of assessments to make capital investment decisions and to adopt common clinical management strategies. This chapter describes how several organizations set priorities for assessments, summarizes models proposed by researchers, and considers how each might contribute to a model process appropriate to the Office of Health Technology Assessment (OHTA)
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If the question is deemed appropriate for a national coverage decision, BPD prepares a background paper for review by the HCFA Physicians Panel. Health Care Financing Administration Physicians Panel The physicians panel serves in an advisory role to BPD.
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Interested parties could thus also request reconsideration and submit evidence published after the initial coverage decision. In summary, issues reach BPD, and hence OHTA, by a process that involves requests for coverage to fiscal intermediaries that have been filtered through the regional offices before reaching BPD.
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Criteria for Reassessment Regulatory agencies worldwide require pharmaceutical companies to conduct continuing studies of their products, including, in some countries, postmarketing surveillance. Determining when reassessment is warranted may also require epidemiologic studies on diseases treated by their products to ensure that condition-related adverse events are distinguished from those that are related to administration of the drug.
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Example 3: Health Care Provider Organizations Many other pnvate-sector entities, including medical specialty societies, medical group practices, hospitals, and health maintenance organizations conduct technology assessment. Two of the better-known programs are the Clinical Efficacy and Assessment Program (CEAP)
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included the potential for an assessment to improve individual patient outcomes, to affect a large patient population, to reduce unit or aggregate costs, and to reduce unexplained variations in medical practice. Secondary criteria represented a "spectrum of factors and issues," including the potential to address social and ethical implications, to advance medical knowledge, to affect policy decisions, and to enhance the national capacity for assessment.
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Using a two-round modified Delphi approach, the priority-setting group chose 20 national assessment priorities from a list of 496 candidate topics. ~ identifying these priorities, the group considered alternative medical technologies that may be used for each of the priority clinical conditions and the multiple clinical indications for the priority technologies.
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for the Methods Panel of the Council on Health Care Technology of the Institute of Medicine; Charles Phelps and Steven Parente developed a different type of quantitative model for the same body. The purposes of these models are to structure thinking, identify the relative importance of the different elements in setting priorities, and provide a framework to evaluate the effect of different assumptions on priority rankings.
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In sum, by estimating the welfare loss associated with the absence of information on technology, the Phelps-Parente model offers a systematic way to derive rankings for priority assessment and to quantity the expected gains from eliminating unwarranted variation in medical practice patterns. SETTING PRIORITIES FOR SPENDING ON HEALTH SERVICES Example 8: Oregon Basic Health Services Act Example 8 is not an example of priority setting for assessment.
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To that end, implementers of the OBHS have adopted four process elements that the IOM committee also sees as essential. First, to estimate potential benefit to the public, the OBHS seeks public participation and uses a broadly representative panel called the Health Services Commission.
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Widespread publicity, for example, about autologous bone marrow transplantation for metastatic breast cancer might induce demand for assessment of this technology; another example of induced demand for technology assessment might be the development of a new device for cataract extraction for which the manufacturer wants Medicare coverage. HCFA and private insurance companies alike use this priority-setting process, which is reactive and, in general, implicit.
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In contrast to assessments of new technologies, assessments of established technologies encounter strong economic and psychological disincentives to change practice, especially for practitioners and hospitals that are frequent users of the technology. Banta and Thacker (1990)
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Analytic Models Both the Eddy and the Phelps-Parente analytic models specify criteria to be used in setting priorities and a formula for combining them; both emphasize the use of empirical data. The Phelps-Parente model uses only available epidemiologic, claims, and practice variation data, whereas TAPSS entails subjective estimates, including estimates of the probability that inforrnation will change behavior.
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It is also important to stress that the priority rankings established by means of an analytic model are inputs to a final derision process, not the final product of the process itself. Need for a Comprehensive, Proactive Process for Priority Setting What sort of process, then, would best serve the public interest?
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From page 45... ...
Nevertheless, priority rankings established by means of an analytic model should be understood as inputs to a final decision process, not the final product of the process itself. APPENDIX: MEDICARE COVERAGE DECISION MAKING The Medicare program, which serves 33 million elderly and disabled beneficiaries and persons with end-stage renal disease, is He responsibility of the Health Care Financing Administration of the Department of Health and Human Services (DHHS)
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and OHTA.3 Such decisions then become national policy.4 Coverage determinations are published in the Medicare Coverage Issues Manual and its accompanying instructions. HCFA issues this manual to the Fls and carriers for claims adjudication and payment and to Medicare peer review organizations (PROs)
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The GIG report recommended that HCFA cooperate with the PHS in proactively and routinely compiling information on new health care technologies and rapidly disseminating it. Dunng any given year, contractors, Medicare beneficiaries, physicians, equipment manufacturers, public officials, professional associations, or government entities request national coverage policy determinations for some 20 to 30 different technologies.
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In the Federal Register of April 29, 1987, HCFA described its process for making coverage determinations and sought comments. In January 1989, following a legal challenge arising from a Medicare coverage issue (Jameson v.
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From page 49... ...
criteria for coverage decisions and "the identification and selection of health care technologies for national coverage decisions," and (2) "methods for assuring appropriate public participation in the various phases of the technology assessment process." The rule also proposed that cost-effectiveness of technologies be a critenon for coverage (see Leaf, 1989~.
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