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, SaskatoonApril 14, 2015

Same, same …

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

*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.

… but different

HTA

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

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

… quite different

HTA

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

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

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

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

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.

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

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

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

Procurement

Learning from HTA Value-based purchasing Evidence-informed

indication and volume management

Methods for clinical pathway management

System-lens on value of technology

Questions?

Thank you