The value and consequences of using public health technology assessments for private payer decision-making in Canada: one size does not fit all

Abstract

Background: Both public and private insurers provide drug coverage in Canada. All payers are under pressure to contain costs. It has recently been proposed that private plans leverage the public health technology assessment (HTA) evaluation process in their decision-making.

Objectives: The objectives of the current study were to examine use of public health technology assessments (HTAs) for private payer decision-making in the literature, to gather the perspectives of experts from both public and private insurers on this practice, and to summarize which value parameters of public evaluations can be used for private payer decision-making.

Methods: A targeted literature review was conducted to identify publications on the use of public HTA or cost-effectiveness data for private payer decision-making on pharmaceutical reimbursement. Concurrently, a roundtable meeting was organized with invited panelists, including private payer representatives and health economic consultants (total n = 9). The findings from both were synthesized and expressed in qualitative terms using the PICO framework.

Results: The targeted review identified 20 studies meeting the inclusion criteria, primarily originating from the US and Canada. The panelists felt that, despite some similarities, there were substantial differences between both systems. The PICO framework highlighted the issues with transferability between the two systems. Most of the value parameters were either not applicable, needed to be added, needed to be adjusted, or their applicability to private payer systems needed to be confirmed.

Conclusion: Some components of public HTA may be relevant for private payers, however there are reservations that still exist on whether the HTA process in Canada, designed for a public system, can address the informational needs of private payers. Private insurers need to use caution in assessing which value parameters from public HTAs can be used and which need to be confirmed, ignored, enhanced, or adjusted. One size HTA does not fit all applications.

Keywords:

• Health technology assessment
• reimbursement
• public payers
• private payers
• decision-making

JEL classification codes:

• I18
• I11

Transparency

Declaration of funding

This study was funded by Amgen, Inc.

Declaration of financial/other interests

LP and MA are employees of Amgen Canada and may own Amgen Inc. stock and/or stock options. RG declares no personal conflict of interest. JME peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Acknowledgements

The authors would like to acknowledge Judith Glennie and Raina Rogoza. Rebecca Liu and Rebecca Hancock-Howard provided writing assistance with this manuscript.