Two Solitudes? HTA & Procurement as Pathways to the Adoption of Non-Drug Health Technologies

Two solitudes? HTA & Procurement as pathways to the adoption of non-drug health technologies FA Miller, C Barg, M Krahn, P Lehoux, S Peacock, VE Rac CADTH, Saskatoon April 14, 2015

Same, same … *Morrison, Michael, and Lucas Cornips. "Exploring the role of dedicated online biotechnology news providers in the innovation economy." Science, Technology & Human Values 37.3 (2012): 262-285. • HTA & Healthcare Procurement share • Roles in supporting the appropriate utilization of health technologies in health systems • Patient outcomes, quality, safety • Public policy attention, given cost pressures and sustainability concerns • Principle missions with respect to health policy • Accordingly, the objects of criticism by industry • Though increasingly asked to consider ‘double promise’* with respect to wealth and health

… but different HTA Procurement Substantial statutory conditions on action Manages adoption for most technologies Subject to trade agreements and statutory directives Creature of Finance/ Treasury Board policy Not always a creature of Health policy Touchstones Fraud & Corruption Waste Competition & Transparency • Limited statutory conditions on action • Provides guidance for limited number of technologies • Subject to limited regulatory directives • Creature of health policy • Touchstones • Evidence-based medicine • Value for money • Patient & social values

… quite different HTA Procurement Adjudicate transparent, fair and competitive process “Request for proposals” Pre-specified criteria Mandatory requirements Envelope 1: Technical/ Quality requirements (Clinical, Service Level, Device and Product Performance Requirements) May involve site trial Envelope 2: Business/Financial requirements • Adjudicate comparative clinical and cost effectiveness • Evidence-based • Critical appraisal of relevant clinical evidence • Value-for money • Cost per QALY • Patient & social values • Patient values & preferences • Citizen values • Accountability for Reasonableness

Study • Role of procurement in adoption of ‘innovative’ non-drug health technologies in Canada • Phase 1: Comparative analysis of procurement arrangements across selected provinces – Quebec, Ontario, Alberta, BC • Case studies – documents, interviews, non-participant observation • Review of Requests for Proposals • Phase 2: Analysis of procurement in practice • Comparative analysis of tracer technologies across sites/ provinces

A brief history of procurement BC, Alberta, Quebec, Ontario

Concurrent developments Organization Regulation Developments in procurement regulation Trade agreements Agreement on Internal Trade, 1995 New West Partnership Trade Agreement, 2010 (Alberta, BC, Saskatchewan) Canadian-European Comprehensive Economic & Trade Agreement (CETA), 2014+ Reform of procurement policy – often driven by scandal Tends to increase formalization & standardization Overlay of new requirements on already complex systems Chilling effect on relations with suppliers • Increases in collective buying power, and efficiencies • Group purchasing organizations – GPOs • Across jurisdictions • E.g., HealthPRO (1996) • Owned by member shareholders across 7 provinces/territories; > 260 members, > 800 facilities • Joint purchasing groups • Within jurisdictions • Often associated with shared “back offices” – so “Shared Service Organizations” (SSOs) • Accounts receivable, Payroll, Technology Services, etc.

BC & Alberta • Organizational reform – 1 Procurement organization • Driven by Ministries of Health • Single centralized mandatory procurement organization • Aligned with scope and budget of regional health authorities (not physician services) • Regulatory reform not dominated by scandal • Quebec • Organizational reform – 3 Procurement organizations • Recent MSSS efforts to reduce number of joint procurement groups and increase use of joint procurement • Partial alignment with scope and budget of ‘regions’ • Regulatory reform dominated by scandal • Ontario • Organizational reform – 9 +++ procurement organizations • Ministry of Finance/ Government & Consumer Services financial encouragement for shared services organizations • MOHLTC AWOL • No alignment with regional scope or budget • Regulatory reform influenced by scandal

Articulation with HTA BC, Alberta, Quebec, Ontario

BC & Alberta • Active effort to coordinate between HTA and procurement • Focus on adoption of novel/ expensive technologies • BC • Health Technology Review committee includes representative from HSSBC • HSSBC conducts “parallel” intake process for health technologies ‘out of scope’ for the Health Technology Review • Alberta • Part of new product introduction/ product evaluation process • Assess whether needs HTA • Regular meetings - CPSM & HTAI • Quebec • Recent directive on mandatory joint procurement • That procurement take into consideration data from HTA • Coordinating & Monitoring Committee includes INESS • Ontario • None

Two solitudes? Conditions for aligning HTA & Procurement

Conclusion, 1 • Public sector procurement a longstanding focus of public policy • Trade agreements • Transparent, non-discriminatory competition • Growing attention to procurement as public policy instrument for other aims • In broader public sector • Reduced costs through volume-based aggregation & purchase efficiencies • In health sector – specific missions • Health outcomes • Quality & safety through product standardization, usability/ safety • In some jurisdictions – other missions • Green procurement, Ethical procurement, Innovation procurement, SME procurement

Conclusion, 2 • Early efforts to elaborate formal connections between HTA & Procurement • Related to capacity to coordinate health ‘system’ • Related to involvement of Health Ministries in health procurement reform • Ontario the outlier in all respects • Even as formal ties develop, disjuncture in evaluative frameworks • Shared knowledge limited • Most RFAs support “lowest cost compliant” bids • Emphasis of shared effort on ‘front end’ • Classic HTA concern with “the new” and expensive

Lessons learned … HTA Procurement Learning from HTA Value-based purchasing Evidence-informed indication and volume management Methods for clinical pathway management System-lens on value of technology • Opportunity for impact • Key for non-drug technologies • Learning from procurement • Understanding the organizational challenges of adoption & use • Comprehensive management of technology – medtech formularies • Valuing other missions • Ethical, green, SME procurement

Questions? Thank you

Two Solitudes? HTA & Procurement as Pathways to the Adoption of Non-Drug Health Technologies