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

Figures & data

Figure 1. Literature review flow diagram of included articles.

Table 1. Summary of 20 identified MEDLINE manuscripts for the literature review.

Reference	Year	Manuscript Title	Country
Fernandez et al.^19	1997	Technology assessment in healthcare: a review and description of a "best practice" technology assessment process.	Not specified
Perry and Thamer^20	1997	Health technology assessment: decentralized and fragmented in the US compared to other countries	US & other (including Canada)
Davis^21	1999	Cost containment mechanisms in Canada	Canada
Philips et al.^22	2004	Review of guidelines for good practice in decision-analytic modelling in health technology assessment	Not specified
Drummond et al.^23	2008	Key principles for the improved conduct of health technology assessments for resource allocation decisions	International
Battista et al.^11	2009	Health technology assessment in Canada	Canada
Bresnahan et al.^24	2009	Findings related to assessing value for private US health plans	US
Bryan et al.^25	2009	Has the time come for cost-effectiveness analysis in US health care?	US
Goeree et al.^26	2009	Health technology assessment and primary data collection for reducing uncertainty in decision making	Canada
Sullivan et al.^16	2009	Health technology assessment in health-care decisions in the United States	US
Weintraub and Cohen^27	2009	The limits of cost-effectiveness analysis	US
Mohr and Tonis^28	2010	Access with evidence development: the US experience	US
Marra et al.^29	2011	Introduction to economic modeling for clinical rheumatologists: application to biologic agents in rheumatoid arthritis	Not specified
Trosman et al.^30	2011	Health technology assessment and private payers’ coverage of personalized medicine	US
Kratzer et al.^31	2013	Cost-control mechanisms in Canadian private drug plans	Canada
Caro and Möller^32	2014	Decision-analytic models: current methodological challenges	Not specified
Klein and Kolodziej^33	2014	Private payers and cancer care: land of opportunity	US
Moloney et al.^34	2015	Payer perspectives on future acceptability of comparative effectiveness and relative effectiveness research	US & Europe
Trosman et al.^35	2017	Decision-making on medical innovations in a changing healthcare environment: insights from accountable care organizations and payers on personalized medicine and other technologies	US
Garrison et al.^36	2018	An overview of value, perspective, and decision context—a health economics approach: an ISPOR Special Task Force report^2	US

Table 2. Important private payer value assessment parameters identified from expert panel.

Value parameter	Why is this important?
How effective is the drug?	• The drug must be as effective or more effective than other drugs currently funded on the formulary
How safe is the drug?	• The drug must have a similar or better safety profile than other drugs funded on the formulary
Is the medicine simpler or more convenient to use?	• Improving adherence (i.e. fewer missed doses, etc.) helps patients achieve the intended benefits of treatment
Does the drug save the patient/family time or money?	• Saving the patient/family member time results in less time away from work and avoids costs associated with doctor appointments (e.g. parking, fuel, transit, etc.)
Will the drug allow patients to return to work sooner?	• Shortening the time for disease treatment and/or disability expedites workers’ ability to return to normal work and home day-to-day functions
Will the drug result in less short-/long-term disability?	• Shortening the time for disease treatment and/or disability improves productivity of the individual and the organization overall
Will the drug reduce the burden on caregivers?	• Reducing caregiver burden means employees are away from work less often (due to patient appointments, patient illness, etc.)

Table 3. Applicability of public HTA analytic approaches and value parameters for private payer decision-making.

Analytic/value parameter	Public consideration	Private consideration	Can public HTA be used for private payer decision-making?
Patient population (P)	Primary focus is on population aged 65 and over.	Primary focus is on working age population.	Maybe. This depends on whether the trial/study population(s) included working age patients. If the data applies mostly to patients aged 65 and over, it needs to be determined whether the efficacy, safety, QoL, and cost information can be generalized to a working aged population.
Intervention (I)	Drug as administered and studied in trial(s).	Drug as administered and studied in trial(s).	Yes.
	Patient preference around method of administration and convenience generally not included.	Patient preference around method of administration and convenience included to the extent they affect work productivity.	No.
Comparator(s) (C)	Drugs considered to be the standard of care or usual practice and which are reimbursed on the public formulary.	Drugs considered to be the standard of care or usual practice and which are reimbursed on the private-payer’s specific formulary.	Maybe, but generally no. The drugs covered under a private plan are usually different than the drugs covered under a public plan. Or the conditions of reimbursement under a public plan (e.g. 2^nd or 3^rd line treatment, after failure of another drug) are usually different under a public compared to private plan.
	Method of administration and patient convenience not included. Adherence generally not included.	Method of administration and patient convenience included to the extent they affect work productivity. Adherence to treatment is considered an important attribute.	No.
Outcomes(s) (O)	Various outcome measures for clinical and pharmacoeconomic analysis (e.g. mortality, event rates, disease progression, biochemical markers, generic and disease-specific QoL, adverse events, other measures of morbidity).	Various outcomes measures but only as they relate to general health status and QoL of the patient and how these impact work productivity (i.e., absenteeism, presentism).	Generally no. The impact of clinical measures on work productivity is usually not reported in a public payer HTA. This partially reflects the fact that perspective of public payer’s HTA is the healthcare system and not the private payer.
	Heavy reliance on efficacy data from randomized controlled trials (RCTs). If relevant comparators are not included in RCTs, then indirect treatment comparisons.	RCT data used, but preference for real world data and real world scenarios. Also preference for insurer data for assessment of outcomes.	No.
	Main HTA pharmacoeconomic outcome expressed as cost per QALY gained (i.e. cost-effectiveness).	Cost per QALY calculations not required.	No. The applicability of a cost per QALY outcome measure is unclear for most private payers, and the relevancy of this outcome measure for private payers has been questioned.
	Various cost components for pharmacoeconomic analysis from the healthcare system perspective (e.g. drug acquisition, administration, monitoring, drug mark-ups, dispensing fees, physician fees, hospitalization costs, ambulatory clinic costs, community care costs, etc.).	Various cost components from a private payer perspective (e.g. drug acquisition, drug mark-ups, dispensing fees, productivity costs including absenteeism and presentism).	No. Although there is some overlap in the cost components included under a healthcare system versus private payer perspective (e.g. drug costs), most of the costing components are different. If costs results are broken down by component, then some costs from a public payer HTA can be used for and private payer cost analysis. However, even for drug costs, the reimbursed price of drugs might be different in the public and private system and theses need to be confirmed. If an alternative scenario analysis is available where a societal perspective is also considered in the public HTA, some of the costs included from this perspective need to be removed for a private payer submission (e.g. patient out-of-pocket and travel costs).
	BIA drug costs including market growth projections, possible market expansion, substitution rates of new drug from existing drugs on public formulary.	BIA drug costs including market growth projections, possible market expansion, substitution rates of new drug from existing drugs on private payer’s specific formulary.	No. Although the time frame (i.e. 3 years) and general methodology is the same for public and private payer BIAs, public payer BIAs cannot be used directly as the private payer BIA needs to be tailored to, and done from, the perspective of the specific private payer and customized to reflect the relevant comparator drugs, market shares, market capture rates, and relative cost of competitor drugs. In addition, private payer BIAs are typically expressed as a cost per 10,000 or 100,000 plan members and not as a budget impact for the entire population like a province.

Table

Attributes	Public system	Private system
Who	Provincial public payers	Private insurance companies
Provider	Single supplier (i.e. the province)	Many suppliers
Economic goal/objective	Welfare maximization Non-Profit organization—extra money goes back in to the system Desire to remain equitable	Profit maximization Profit making organization with accountability to shareholders Desire to remain competitive
Who do they answer to	Canadian population (society)	The purchaser of insurance Shareholders
Who do they cover	The Canadian population to varying degrees—on an individual level (homogenous group)	Those for whom a private insurance package is purchased and their family (heterogeneous group)
What do they cover	All hospital costs for whole population. All costs for over the age of 65 years or those on benefits	The extent of coverage is dependent on the package purchased. No in hospital costs are covered
Funding model	Paid for by taxes; finite amount. Depends on transfer payment from federal government; amount related to national priorities and determined at the provincial level (explain how public system is funded in the text)	Paid for by insurance premium; customer chooses how much he is willing to pay for what benefits he wants to receive
Tax implications	Taxes fund the system No tax benefit for the beneficiary	Private insurance is a tax-deductible benefit for employer and tax free benefit for the employee Insurer pays taxes on their revenue stream
Perspective/willingness to pay	Healthcare system (exclude QC)	Worker and family (societal)
Extra insurances for high cost patients	None	Pool fund or additional purchase of insurance
Incentives	Population health	For companies purchasing insurance: importance is placed on: Worker retention (replacing an employee is costly), Productivity and absenteeism, Worker recruitment benefit

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