Health Technology Assessment (HTA) in Universal Health Coverage (UHC) SURACHAT NGORSURACHES, PH.D. HTA Forum, ISPOR 7 th Asia-Pacific Conference, Singapore Disclosure I have no actual or potential conflict of interest in relation to this program/presentation. 1
Outline Country profile Roles of HTA in UHC Key success factors Challenges Key areas for improvement Conclusions Country Profile 2
Thailand Population: 67.7 millions (2014) 3 major health benefit schemes Civil Servant Medical Benefit Scheme (CSMBS) 12% Social Security Scheme (SSS) 13% Universal Health Coverage Scheme (UHC) 74% Total health expenditure (% of GDP) 12 10 8 6 4 2 0 2006 2007 2008 2009 2010 2011 2012 2013 2014 World Thailand Upper middle income Source: World Bank 3
Health expenditure per capita (US$) 1200 1000 800 600 400 200 0 2006 2007 2008 2009 2010 2011 2012 2013 2014 World Thailand Upper middle income Source: World Bank Roles of HTA in UHC 4
Development of HTA in Thailand 1 st HTA publication 1990 HTA unit 2005 HITAP 2007 Decisions w/ HTA 1982 2002 2006 2009 Center of HE ISPOR Thailand HTA guideline Teerawattananon et al. 2009 HTA should always be part of the priority setting process, and is an essential foundation to secure UHC (Chalkidou et al. 2013) National guidelines for HTA e.g. CEA, CUA, Ethical considerations Cost-effectiveness threshold: 1 GNI per capita per QALY gained 5
Uses of HTA Drug benefit package National List of Essential Medicines (NLEM) Health benefit package UHC coverage plan e.g. diagnosis, treatment, prevention, health promotion, supplementary list for medicines National list of essential medicines (NLEM) Topic selection Conducting HTA research Appraisal Specialty working groups (i.e. clinicians) Clinical evidences ISafE score EMCI (cost per ISafE) Health economics working group (i.e. clinicians, health economists) CEA, CUA Budget impact Consolidation working group Subcommittee for NLEM development 6
Sublists: ก, ข, ค, ง, จ A reimbursement list for all 3 schemes UHC health benefit package CEA, CUA, BIA Stakeholders Working group HITAP/ Researchers Committee NHSO Board Nomination of interventions Prioritization Assessments Appraisals Decisions Magnitude, severity Tantivess 2013 7
Pegylate interferon alpha 2a&2b plus ribavirin for treatment of chronic hepatitis C sybtype 1 4 5 & 6 ICER (Baht/QALY) Cost-saving Coverage decisions Lamivudine or tenofovir for treatment of chronic hepatitis B Cost-saving Yes AZT+3TC+LPV/r for PMTCT Cost-saving Yes Provider-initiated HIV testing 70,000 Yes Statin in pop >30% CVD risk 82,000 Yes Nilotinib for the second-line treatment of chronic myeloid leukemia Oxaliplatin (FOLFOX) for treatment of advance colorectal cancer Yes 86,000 Yes 126,000 Yes Galantamine for treatment of mild-to-moderate Alzheimer s disease 157,000 No Donepezil, rivastigmine for treatment of mild-to-moderate Alzheimer's disease 180,000-240,000 No IV/OR form of ganciclovir for CMVR 185,000 Yes Pioglitazone for DM 211,000 No HPV vaccine for girls aged 15 years 247,000 No Alendronate or residronate for osteoporosis 296,000-328,000 No ICER (Baht/QALY) Coverage decisions Cochlear implantation for profoundly deaf 400,000 No Peritoneal dialysis for ESRD 435,000 Yes Hemodialysis for ESRD 449,000 Yes Foldable lens for cataract 507,000 No Atorvastatin in pop >30% CVD risk 600,000 No Erythropoitin for anemia in cancer 2,700,000 No Imiglucerase for treatment of Gaucher disease type 1 6,300,000 Yes Adefovir, entecavir, telbivudine, pegylate interferon alpha 2a for treatment of chronic hepatitis B Negative dominant No Tantivess 2013 & WHO Note 8
Examples of price negotiation Price before negotiation (Baht) Price after negotiation (Baht) Annual saving (Baht) Tenofovir 43 12 375M Peg-2a 180mcg 9,241 3,150 600M Tantivess 2013 Key success factors for HTA in UHC Finance HITAP (US$1 million a year) Limited resources for health care in UHC Capacity HTA body s own capacity Stakeholder engagement Transparency 9
Challenges Efficiency: Is NLEM a perfect list? Sublist: จ (2) Cost-effectiveness threshold (1.2 GNI ~160,000 Baht) Budget impact Still, No cost sharing Not listed in NLEM = full payment 10
Weeks Equity Capitation (UHC, SS) VS Fee-for-service (CSMBS) UHC: supplementary list by drug fund economic evaluation price negotiation: epidemiology data, price-volume agreement International reference price Timeliness Limited HTA capacity From regulatory approval to subsidized patient access 120 100 80 60 40 20 0 Japan Australia New Zealand S Korea Thailand Taiwan Registration Listing Minimum time from regulatory approval to subsidized access Source: Cook and Kim (2015) 11
Launch time of innovative medicines Januvia/ DM Pradaxa/ CVS Sutent/ ONCO # of months after the first launch 1-6 7-12 13-18 19-24 25-36 37-48 >48 2006 BRA UK, GER TAI, THA AUS, FR,KR, IN 2008 GER, UK AUS, BRA, FR 2006 GER, UK AUS, BRA, FR CHI THA KR, TAI IN, CHI KR, TAI THA IN, CHI Source: IMS (2015) 2014 2015 Pharmaceutical sales (US$ Billion) 4.48 4.46 Pharmaceutical sales (% GDP) 1.11 1.13 Pharmaceutical sales (% of Health expenditure) 25.3 24.9 Source: BMI Research 12
8.5 Crude death rate (per 1,000 people) 8 7.5 7 6.5 6 5.5 5 2006 2007 2008 2009 2010 2011 2012 2013 2014 World Thailand Upper middle income Source: World Bank Key areas for Improvement Capacity building Key success: Building up our own troops (Tantivess 2013) HTA agency There is no agreed format for HTA, and the shape of an HTA body in a particular country is influenced by that country s healthcare system and the level of government involvement in it. (EUPATI, 2015) 13
Conclusions No single tool to make innovative medicines accessible to Thai patients Be dynamic Competition among intelligent partners Common goal PATIENTS 14
Thank you 15