6 Concluding Comments – Policy Issues
There are a number of issues arising from the findings of this analysis:
First, are the issues of cost- and clinical effectiveness. While the stent itself is cheaper than performing a CABG, the evidence has shown that it is associated with an increase in coverage thus generating an increase in health expenditure. However, this study does not take into account the associated benefits of a healthier workforce, reduced morbidity and mortality rates which clearly need to come into the equation when deciding whether to adopt a particular technology.
Second, there is the question of who benefits from the technologies and whether these benefits are accessible to all (and indeed whether they need to be!). In the case of coronary care, the evidence suggests that groups other than NZ European are underrepresented in the data so this calls into question (a) whether technology is disseminating appropriately or (b) whether the access problems exist at the primary care level hence a smaller number of referrals for coronary procedures.
6.1.1 There is a trade off between regulating the spread of a new technology and providing incentives for innovation
As outlined in the literature survey, we face a difficult trade off. If technological advances are constrained by too many layers of bureaucracy, this is likely to act as a deterrent to a number of valuable advances. Until recently, the set up in New Zealand allowed for new technologies to spread with little or no regulation (e.g. drug eluting stents). As such, more costly procedures could disseminate the market with only limited evidence supporting their use.
In May 2005, the National Health Committee put together a report to the Minister of Health setting out recommendations for a health intervention process (Decision Making about New Health Interventions, 2005). The Ministry of Health and DHBNZ have subsequently put into place the Service Planning and New Health Intervention Assessment (SPNHIA). The new procedures call for a more collaborative decision making process between DHBs, the Ministry of Health and other related bodies.
The process has already been trialled in the provision of brachytherapy (a procedure in which radioactive material is placed directly into or near the cancer. The radiation is sealed in needles, seeds, wires, or catheters.) To date, the process has been deemed a success with brachytherapy now reaching the third phase of the process. However, there are critics who note that there are too many layers of bureaucracy and hence the process is longer than it need be.
One may also argue that a technology may be introduced into medicine, highly regarded and disseminated widely yet clinical and cost evidence can only follow with a considerable lag. It is too early to say whether stents demonstrate long term efficacy or differ significantly from a clinical or overall cost basis from other coronary procedures.
Meanwhile, James Harris has suggested that we meld some of the positive features of the UK’s National Institute for Clinical Excellence (NICE) and PHARMAC. In particular he points to NICE’s breadth of scope and PHARMAC’s ability to negotiate over price, its evaluation and budgetary processes. Together this could improve New Zealand’s resource allocations through a national technology assessment process.
While an institution like PHARMAC is not always popular with clinicians, it has proven success for dealing with drug companies and constraining costs. In its recent publication (Annual Review 2004) it compares pharmaceutical costs with what would have emerged in the absence of regulation. The volume of drugs prescribed has climbed steadily with costs remaining stable in recent years. It will be interesting to see if the new SPNHIA process is able to deliver this type of service.
6.1.2 Final Comments
Empirical evidence suggests that technology changes account for a significant proportion of health expenditure. While key studies for New Zealand are scarce, early findings suggest that it is likely that new interventions play just as significant a role in health spending as for other countries (Bryant et al., 2004). However, at present New Zealand’s framework for assessing new interventions is still in its infancy. As such this paper provides the first steps in analysing the way in which new technologies reach patients.
Clearly, there are still a number of issues to be addressed and much work to be performed in the area. However, it is hoped that by examining technology advances in the cardiac area we will shed light on how the current system works and how processes can be made more efficient in the future.
