Priority setting for high cost medications (HCMs) in public hospitals in Australia: A case study

Centre for Health Economics Research and Evaluation (CHERE), University of Technology, Sydney, PO Box 123, Broadway, NSW 2007, Australia.
Health Policy (Impact Factor: 1.91). 12/2007; 84(1):58-66. DOI: 10.1016/j.healthpol.2007.05.008
Source: PubMed


Health care providers (HCPs) are increasingly aware of pressures on funding for health care services, including high cost medicines (HCMs). Allocating resources to innovative and expensive medications is particularly challenging and the decision-making processes and criteria used to allocate resources to HCMs have not been widely described in the literature. This case study aimed to describe the operations of the first reported High Cost Drug Sub-Committee (HCD-SC) in a public hospital in Australia. In addition the study also evaluated the decision-making process using Daniel and Sabin's ethical framework of "accountability for reasonableness". Some lessons emerged from the description of the operations of the HCD-SC. Decisions were not solely based on effectiveness and cost. Additional factors such as "clinical need" and the lack of an alternative treatment were involved in decisions about access to HCMs. Members of the HCD-SC also considered it was important to have consistency in the way decisions were being made. The findings from this study provide an evidence base for developing strategies to improve this hospital's decision-making process regarding access to HCMs.

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    • "To explore the relevance of procedural characteristics that are important in legal studies and social psychology to social choice contexts and provide evidence on their relative importance. To explore why certain procedural conditions are considered important Friedman 22 2008 Conceptual - - No specific priority setting activity To critically examine the accountability for reasonableness framework Gallego 23 2007 Empirical Australia An Australian teaching and tertiary care hospital Medicine selection To describe and evaluate the medicine selection process for high cost drugs in an Australian hospital Gibson et al 24 2004 Empirical Canada A Canadian academic health science center Resource allocation across hospital service areas and departments To assist decision-makers in a Canadian academic health center to develop fair priority setting processes Gibson et al 25 2005 Empirical Canada An Canadian urban academic health center Resource allocation across hospital service areas and departments To examine the influence of power dynamics among actors to the priority setting processes in a Canadian hospital Gibson et al 26 2006 Empirical Canada A health region in Canada Allocation of healthcare resources within the district/region To evaluate the use of PBMA at a health region in Canada Gordon et al 27 2009 Empirical Argentina An Argentinean acute care tertiary hospital Resource allocation across hospital service areas and departments To describe and evaluate the priority setting process in an Argentinean hospital with particular attention to the appeal process Greenberg et al 28 2005 Empirical Israel The National health insurer in Israel Medicine selection To evaluate the adoption of new technologies at the hospital level in Israel Kapiriri and Martin 29 2006 Empirical Uganda A 1500 bed tertiary hospital in Uganda Resource allocation across hospital service areas and departments To describe the priority setting practice in a tertiary care hospital in Uganda and evaluate the process Kapiriri and Martin 30 2007 Empirical Uganda Three hospitals, one in Norway, one Uganda, and one in Canada Resource allocation across hospital service areas and departments To describe and evaluate priority setting practices at the macro, meso and micro levels of the health systems in "
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    ABSTRACT: Background: Priority setting in healthcare is a key determinant of health system performance. However, there is no widely accepted priority setting evaluation framework. We reviewed literature with the aim of developing and proposing a framework for the evaluation of macro and meso level healthcare priority setting practices. Methods: We systematically searched Econlit, PubMed, CINAHL, and EBSCOhost databases and supplemented this with searches in Google Scholar, relevant websites and reference lists of relevant papers. A total of 31 papers on evaluation of priority setting were identified. These were supplemented by broader theoretical literature related to evaluation of priority setting. A conceptual review of selected papers was undertaken. Results: Based on a synthesis of the selected literature, we propose an evaluative framework that requires that priority setting practices at the macro and meso levels of the health system meet the following conditions: (1) Priority setting decisions should incorporate both efficiency and equity considerations as well as the following outcomes; (a) Stakeholder satisfaction, (b) Stakeholder understanding, (c) Shifted priorities (reallocation of resources), and (d) Implementation of decisions. (2) Priority setting processes should also meet the procedural conditions of (a) Stakeholder engagement, (b) Stakeholder empowerment, (c) Transparency, (d) Use of evidence, (e) Revisions, (f) Enforcement, and (g) Being grounded on community values. Conclusion: Available frameworks for the evaluation of priority setting are mostly grounded on procedural requirements, while few have included outcome requirements. There is, however, increasing recognition of the need to incorporate both consequential and procedural considerations in priority setting practices. In this review, we adapt an integrative approach to develop and propose a framework for the evaluation of priority setting practices at the macro and meso levels that draws from these complementary schools of thought.
    International Journal of Health Policy and Management (IJHPM) 10/2015; 2015(411):719-732. DOI:10.15171/ijhpm.2015.167
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    • "In the face of these developments, there has yet to be research exploring how Ps&Ps could be involved in reimbursement decision-making for " orphan drugs " or drugs for rare diseases (DRDs), and what role they might play in that process – some exceptions notwithstanding [11] [12]. As we detail below, reimbursement decision-making for DRDs poses supplementary challenges to the ones already facing decision-making for common drugs or other areas of research and care. "
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    ABSTRACT: Recently there has been an increase in the active involvement of publics and patients in healthcare and research, which is extending their roles beyond the passive recipients of medicines. However, there has been noticeably less work engaging them into decision-making for healthcare rationing exercises, priority setting, health technology assessment, and coverage decision-making. This is particularly evident in reimbursement decision-making for ‘orphan drugs’ or drugs for rare diseases. Medicinal products for rare disease offer particular challenges in coverage decision-making because they often lack the ‘evidence of efficacy’ profiles of common drugs that have been trialed on larger populations. Furthermore, many of these drugs are priced in the high range, and with limited health care budgets the prospective opportunity costs of funding them means that those resources cannot be allocated elsewhere. Here we outline why decision-making for drugs for rare diseases could benefit from increased levels of publics and patients involvement, suggest some possible forms that involvement could take, and advocate for empirical experimentation in this area to evaluate the effects of such involvement. Focus is given to the Canadian context in which we are based; however, potentialities and challenges relating to involvement in this area are likely to be similar elsewhere.
    Health Policy 01/2015; 119(5). DOI:10.1016/j.healthpol.2015.01.009 · 1.91 Impact Factor
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    • "While clinicians, who subscribe to the 'medicalindividualistic' decision system, were concerned with individual patient outcomes, administrators/managers, who subscribe to the 'fiscal-managerial' decision system, were concerned with the implications of decisions on the budget (Danjoux et al. 2007; Gordon et al. 2009). This conflict was more evident in scenarios where decisions affected identifiable patients such as medicines selection processes (Gallego et al. 2007). "
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    ABSTRACT: Priority setting research has focused on the macro (national) and micro (bedside) level, leaving the meso (institutional, hospital) level relatively neglected. This is surprising given the key role that hospitals play in the delivery of healthcare services and the large proportion of health systems resources that they absorb. To explore the factors that impact upon priority setting at the hospital level, we conducted a thematic review of empirical studies. A systematic search of PubMed, EBSCOHOST, Econlit databases and Google scholar was supplemented by a search of key websites and a manual search of relevant papers' reference lists. A total of 24 papers were identified from developed and developing countries. We applied a policy analysis framework to examine and synthesize the findings of the selected papers. Findings suggest that priority setting practice in hospitals was influenced by (1) contextual factors such as decision space, resource availability, financing arrangements, availability and use of information, organizational culture and leadership, (2) priority setting processes that depend on the type of priority setting activity, (3) content factors such as priority setting criteria and (4) actors, their interests and power relations. We observe that there is need for studies to examine these issues and the interplay between them in greater depth and propose a conceptual framework that might be useful in examining priority setting practices in hospitals.
    Health Policy and Planning 03/2014; 30(3). DOI:10.1093/heapol/czu010 · 3.47 Impact Factor
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