Third Plenary Session FAIRNESS FIRST? SOCIAL VERSUS INDIVIDUAL PREFERENCES. Christian Affolter, PhD, MBA

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1 Third Plenary Session Speaker FAIRNESS FIRST? SOCIAL VERSUS INDIVIDUAL PREFERENCES Christian Affolter, PhD, MBA Head of Foundations santésuisse Solothurn, Switzerland FAIRNESS FIRST? SOCIAL VERSUS INDIVIDUAL PREFERENCES ISPOR 15th Annual European Congress Third Plenary Session social preferences within the SwissHTA process Christian Affolter, santésuisse : Datum:

2 Situation in Switzerland Swiss health care legislation dominated by a focus on solidarity (?) and the provision of support for those in greatest need system of compulsory health insurance, equal (and fair?) access to a wide range of technologies very high costs (11% of GDP) need to improve quality and efficiency need for sustainable financing of health insurance and alternatives to rationing Situation in Switzerland BUT: solidarity conflicts with the wish of low taxes and insurance rates solidarity conflicts with individual preferences and moral hazard conflicting goals: Optimizing towards what (fairness, high Quality, sustainable financing)? do we really know what people want? 2

3 SwissHTA - a consensus project cornerstones an inclusive process open to Swiss HTA stakeholders taking into account existing experiences with formal HTAs in other countries with explicit reference to the status of international development focusing on the expectations (i.e. the social preferences ) of the Swiss population taking into account the implications for operationalizing the criteria for efficacy, suitability and cost-effectiveness with clear standards for a differentiated evaluation of new and existing technologies SwissHTA consensus: stakeholder involvement Project initiated in 2010 by Interpharma and santésuisse Steering group and sponsorship of SwissHTA Interpharma (association of Swiss research based pharmaceutical companies) santésuisse (association of Swiss health insurers) Swiss Medical Association (FMH) Swiss Academy of Medical Sciences (SAMS) Swiss Conference of the Cantonal Ministers of Public Health (GDK, as observer) Federal Office of Public Health (FOPH, as observer) Scientific Advisory Board Prof. Michael Schlander, University of Heidelberg, InnoValHC Prof. Gérard de Pouvourville, ESSEC Paris Prof. Robert Leu, University of Berne 3

4 Swiss HTA: Goals to provide support to decision makers in charge of reimbursement and pricing of interventions regular reevaluation of any such decisions identification of evidence gaps and research needs broad stakeholder involvement throughout all stages of HTA process provision of information to ensure fair access to high quality, effective and efficient health care interventions focus on the expectations (social preferences) of Swiss population within the limits of normative standards in the sense of Swiss legal tradition Primary normative postulate empirical preferences are not a sufficient for decision-making must be embedded in the context of a prior normative commitment derived from constitutional provisions and legal tradition of Switzerland (equal rights, protection of children, right to assistance in emergency situations and other norms) focus on a concept of personality, integrity and autonomy of the individual and health as a conditional good equal access to appropriate health care 8 4

5 Social preferences, a major input within the prior normative commitment, the expectations ( social preferences ) of the Swiss population for resource allocation should guide decision-making beyond efficiency goals, these include fairness objectives and equal access, preferences for reciprocity and altruistic motives corresponds to the concept of empirical ethics with health care resource allocation being directed to best meet the expectations and the needs of the insured WZW criteria for resource allocation: Efficacy, Suitability, Cost-effectiveness decisions about the allocation of health care resources in Switzerland have to comply with the so called WZW criteria stipulated by the Swiss Health Insurance Act (KVG) Wirksamkeit: Efficacy Individual benefits perspective additional health related benefits conferred by a technology in comparison to the existing standard of care Zweckmässigkeit:Suitability social benefits perspective Meeting the purpose and objectives of the health insurance system as defined by the social preferences of the Swiss population (i.e., social desirability ), constrained by the prior normative commitment Wirtschaftlichkeit: Cost-effectiveness cost perspective economic impact of funding a health technology 5

6 the new Z: Assessment of suitability the assessment of suitability adds a social perspective to the individual perspective of the cost-effectiveness assessment suitability consists of an examination for conformity with the priority objectives of solidarity-based healthcare within the limits covered by compulsory health insurance essential elements are not only normative premises, but also empirically demonstrable expectations, including the willingness to accept trade-offs (social preferences) the new Z: Social preferences Based on surveys and international studies, the following social preferences are postulated (working hypothesis): Priority for interventions in especially acute and/or especially severe disorders (criterion of urgency and severity) Special consideration of interventions for young people (criterion of a fair innings ) A fair chance of access to effective medical care even in the case of rare diseases and / or high costs of intervention (criterion of fairness) Subordination of interventions for minor disorders and / or in cases where selffinancing may be reasonably expected (criterion of bagatelles ) As far as possible unhindered general and prompt access to new interventions that offer demonstrable added benefit (criterion of innovations) 6

7 Need for setting limits social preferences should give the boundaries for acceptable limits limits are derived from the criteria of efficacy, suitability and cost-effectiveness and include added health-related benefits and their evidence influence of budgetary impact (or opportunity cost from a system s perspective) exclusion of inefficient technologies exclusion of bagatelles (based on triviality of disorder or possible selffinancing) allocative efficiency (measured as maximum individual willingness-to-pay or QALYs) is not sufficient as it is concerned with interpersonal comparisons as the results could be unethical when examined against the prior normative commitment and the social preferences Swiss HTA rejects the idea of uniform cost per QALY benchmarks. What do we know in Switzerland? No high-level empirical studies social preferences of the Swiss population with regard to health care resource allocation decisions are available BUT: It is not as bad as it looks. There are some sources available: democratic processes in Switzerland with their open debates develop some ideas about social preferences e.g. a broad debate started after the decision following an HTA that complementary medicine shows no therapeutic effect and therefore will not be paid by compulsory health insurance. Highlight was then, that in 2009 a legislative initiative was accepted, forcing government to foster complementary medicine. 14 7

8 What do we know in Switzerland? court rulings concerning the reimbursement of therapies not covered by compulsory health insurance open debates e.g. reimbursement of Myozyme: courts started to set limits (CHF /QUALY) and give advice for technology appraisals. Regular surveys of people s opinion to health related questions gfs.bern/interpharma, Gesundheitsmonitor study sondage santé Discussions about single cases in tabloid press, e.g. expensive therapies for older people or VIPs, non-treatment of young people, discrimination of hedonistic based diseases. Further development Research needs include empirical studies of the social preferences of the Swiss population with regard to health care resource allocation decisions development of improved economic evaluation methods that enable capturing these social preferences variable cost/qaly benchmarks as a function of the severity and frequency of a disorder direct methods of measuring relative social willingness to pay 8

9 We would do it again! Swiss HTA believes that the results achieved provide a basis for, and encourage continued strong stakeholder involvement in the implementation and further evolution of HTA in Switzerland at the federal level. Result of the consensus process