A DELICATE BALANCE: Resource allocation in cardiovascular care - - PowerPoint PPT Presentation

A DELICATE BALANCE: Resource allocation in cardiovascular care

Eric A. Cohen MD, FRCPC

Schulich Heart Centre, Sunnybrook Health Sciences Centre Toronto, ON ACC Rockies

Banff AB, March 2013

Rational Allocation of Cardiovascular Care

Disclosures

• Relevant to this presentation, ERIC COHEN has received financial

support within the past three years for consulting and/or CME from:

• sanofi-aventis
• Eli Lilly
• AstraZeneca
• Novartis
• Sepracor / Sunovion
• Medtronic
• Boston Scientific
• Abbott Vascular

October, 2012

Rational Allocation of Cardiovascular Care

Additional disclosures

• Advisory
• Ministry of Health & Long-Term Care (Ontario)
• Cardiac Care Network
• Health Quality Ontario
• Health Canada
• Administrative
• Schulich Heart Program, Sunnybrook Health Sciences Centre

Rational Allocation of Cardiovascular Care

Outline

• Dilemmas
• Insights
• A conceptual proposal for change

Rational Allocation of Cardiovascular Care

Dilemma #1

• You’re an interventional cardiologist about to stent the mid-RCA of a non-

diabetic 72 year old woman

• The lesion is a bit long (20-25 mm) but the vessel is large (3.5 mm)
• Her brother had PCI and a lot of difficulty with restenosis
• A bare metal stent in your lab costs $300 and a drug eluting stent $900
• What type of stent are you going to implant?

Rational Allocation of Cardiovascular Care

Dilemma #2

• You are the (physician) cardiac program director in a large hospital with a

structural heart program.

• Your team has been doing 40 TAVI procedures per year using donated funds,

but the waiting list is growing and several patients have died while waiting, including 2 last week.

• The CEO (also a physician) has made it clear there are no funds from outside

the cardiac program to increase TAVI volume, but has suggested that you as program director could impose a reduction on the use of drug-eluting stents and use the savings to fund additional TAVI cases.

• The patient currently #7 on the TAVI wait list – as well as the woman in

dilemma #1 – are both anxiously awaiting your decision.

Rational Allocation of Cardiovascular Care

Dilemma #3

• You’re a pharmacist with responsibility for publicly funded drug

reimbursement in a hypothetical province.

• You’ve received funding requests for several new anti-platelet / anti-

coagulant drugs that appear to show clinical benefit and in some cases reasonable cost-effectiveness.

• The current drug budget is at its limit.
• Under new rules to enhance accountability in the public sector, your own

salary is subject to performance bonus or penalty, according to whether the drug budget is under- or over-spent.

• Drug companies, cardiologists, and the woman in dilemma #1 all await your

decision

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Dilemma #4

• You’re the Minister of Health (of the same hypothetical province).
• Your own riding has no invasive cardiac centre; there is pressure from the

community and from local cardiologists to establish a new cath facility.

• You understand the benefits of prompt access to cath, but you’ve also heard

concerns about the relatively low volume of procedures that will be done.

• You are frustrated because despite convening (and paying for) a so-called

“expert consensus panel” there seems to be no consensus.

• Your constituents, the local cardiologists, and – you guessed it - the woman

in dilemma #1 - all await your decision.

Rational Allocation of Cardiovascular Care

What is unique about resource allocation in the cardiovascular domain?

1.

Magnitude (clinical and economic)

2.

Potential lethality

3.

Non-linear relationship between treatment and outcome

4.

Abundance of technology

Rational Allocation of Cardiovascular Care

Insight #1: These are complex decisions

Allocation Decision

Clinical evidence Economic analysis Ethics & values Guidelines, Appropriate use criteria Affordability Politics and timing

• Multiple inputs, each with a

degree of uncertainty

• No clear rules on weighting

the various inputs

• In this context, can

allocation decisions ever be truly “rational”?

Rational Allocation of Cardiovascular Care

Insight #2: Being smart is not enough

• His job is all about resource

allocation decisions

• “Infinite” budget but finite

salary cap

• He’s very smart (Harvard

Law 1981)

• He was successful – on the

balance sheet . . . . .

• But that wasn’t enough

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Insight #3: Allocation happens anyway

Example: ST elevation MI

• One of the most common . . .
• One of the most clearly defined . . .
• One of the most studied . . .

Rational Allocation of Cardiovascular Care

Conditions of all time

Insight #3: Allocation happens anyway

Rational Allocation of Cardiovascular Care

Allocation Decision

Clinical evidence Economic analysis Ethics & values Affordability Politics and timing Guidelines, Appropriate use criteria

Explicit values and preferences

Values and preferences. This recommendation places relatively greater weight on the absolute reduction of stroke risk with OACs compared with ASA and less weight on the absolute increased risk for major hemorrhage with OACs compared with ASA.

Rational Allocation of Cardiovascular Care

Insight #4: Cost-effective ≠ affordable

Pharmaco-economic evaluation of new oral anticoagulants: CHADS2 < 2

• Dabigatran 110 mg BID:

Inremental cost per QALY gained = $86,831

• Apixaban 5 mg BID

Incremental cost per QALY gained = $34,572

• Dabigatran 150 mg BID

Incremental cost per QALY gained = $20,845

Rational Allocation of Cardiovascular Care

Rational Allocation of Cardiovascular Care

Insight #5: It helps to be a bit skeptical . . .

• Two ethical arguments for avoiding waste
• that patients should not be deprived of useful medical services so long as money

is being wasted on useless interventions

• and that useless tests and treatments cause harm through false-positive results

and complications

• Thus, wasteful, non-beneficial medicine imposes opportunity costs

for patients in need and also conflicts with the medical maxim of "First, do no harm."

Rational Allocation of Cardiovascular Care

• Don’t screen asymptomatic

patients with stress tests or imaging

• Don’t do stress tests or

imaging as routine f/u

• Don’t do routine stress or

imaging for pre-op evaluation

• Don’t do routine f/u echo

for mild valve disease

• Don’t stent non-culprit

lesions in patients with STEMI

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Rational Allocation of Cardiovascular Care

DES – a potentially wasteful technology?

Rational Allocation of Cardiovascular Care

2,715 physicians

Rational Allocation of Cardiovascular Care

Variation and high rate of DES use in low-risk patients – what motivates physicians?

• Belief that benefits extend beyond trial enrolment criteria
• Influence of prior adverse experience
• Allure of technology for it’s own sake
• Influence of industry marketing
• Pressure from patients
• Most importantly, few interventional cardiologists or their patients face

financial incentives at the point of care encouraging a choice of stent that maximizes economic value. In a “price-free” environment, the natural inclination is to select the more expensive option.8

Rational Allocation of Cardiovascular Care

• State-of-the-art management methods, research on comparative

effectiveness, and incentives for providers to apply this know-how can make care cheaper and better.

• It has become common wisdom that 30% of health care spending, or

$800 billion a year, is wasted on ineffective measures.

• But cutting this 30% is a distant hope. Useless care, critics note, is

easy to spot after the fact; it's much more difficult to recognize at the moment of clinical decision.

Rational Allocation of Cardiovascular Care

Rational Allocation of Cardiovascular Care

Rational Allocation of Cardiovascular Care

Insight #6: Cutting wasteful spending won’t be enough

• Berwick & Hackbarth. Eliminating waste in US health care. JAMA 2012;307:1513
• A significant proportion of health spending is

wasteful . . . as much as 30% in US

• Despite best efforts at waste avoidance, there will

likely be beneficial therapies too expensive to afford

Allocation Decision

Clinical evidence Economic analysis Ethics & values Guidelines, Appropriate use criteria Affordability Politics and timing

Insight #7: Payers are allowed to say no

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Federal Common Drug Review – Ticagrelor

December 2011

Recommendation: The Canadian Drug Expert Committee (CDEC) recommends that ticagrelor not be listed at the submitted price. Reasons for the Recommendation:

• 1. The pre-specified subgroup analysis . . . in a North American population.
• 2. . . . the cost-effectiveness of ticagrelor could not be properly assessed.
• 3. The daily cost of ticagrelor ($2.96) is greater than clopidogrel ($2.58).

Of Note: Based on a review of the clinical evidence, the Committee felt that a reduced price would increase the likelihood of a recommendation to “list” or “list with criteria”.

Rational Allocation of Cardiovascular Care

Insight #8:

Rationing occurs in Canada and is not always explicit

• The True North strong and . . . implicitly rationed
• Geographic
• Socio-economic
• Inter-jurisdictional disparity
• Philanthropy
• Cultural reluctance to discuss limits of publicly funded health

care

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Insight #9: Canada needs a vigorous debate!

Rational Allocation of Cardiovascular Care

Canadians have universal coverage . . .

Americans don’t. But they do have . . .

• Major legislative reform
• Multiple “experiments” with

various models of care delivery

• A meaningful debate
• n health care

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Insight #10: Patients have very little input

Allocation decisions ultimately impact individuals

Rational Allocation of Cardiovascular Care

Insight #10: Patients have very little input

Allocation Decision

Clinical evidence Economic analysis Ethics & values Guidelines, Appropriate use criteria Affordability Politics and timing

• Input at the political level

(theoretically)

• Input to a debate on

societal values (if such a debate ever took place)

• But no opportunity to allow

personal values (including willingness to pay) to influence type of care and potential outcome

Rational Allocation of Cardiovascular Care

Summary – Top Ten List

1.

This is complex. Don’t expect highly proscriptive answers.

2.

Clinical evidence will always be incomplete. Uncertainty happens.

3.

We allocate anyway, based on a mix of analysis and feel.

4.

Payers are allowed to say no, but need to be explicit.

5.

Canadians are sheltered behind the illusory and quasi-religious status of universal health care; we need more transparency and

• pen debate on fundamental change.

6.

Accountability and incentives could be restructured to achieve meaningful reform.

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Non-sustainability

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Moving forward

• Values that differ among individuals and groups
• Differences in ability to pay but also in willingness to pay
• Inevitable uncertainty of clinical evidence
• often around subgroups
• Various parties acting as patients’ “agent” representing clinical and

economic interests – except the patient

• Insufficient financial incentives on both patients and providers to allocate

rationally

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Rational Allocation of Cardiovascular Care

Pay for uncertainty

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High level of certainty of benefit High level of certainty of no benefit Uncertainty Who benefits?; how much?

Current situation?

Rational Allocation of Cardiovascular Care

High level of certainty of benefit High level of certainty of no benefit Uncertainty Who benefits?; how much?

Publicly funded

Not available

Current situation?

Rational Allocation of Cardiovascular Care

High level of certainty of benefit High level of certainty of no benefit Uncertainty Who benefits?; how much?

Publicly funded

Available but not publicly funded

eg prasugrel, ticagrelor eg cardiac rehab in some situations eg routine screening stress test

Potential future situation as funding becomes linked to appropriateness

Rational Allocation of Cardiovascular Care

High level of certainty of benefit High level of certainty of no benefit Uncertainty Who benefits?; how much?

Publicly funded

Not funded and not available

eg TAVI (until recently) eg DES for low restenosis risk eg non-culprit revascularization in STEMI eg LAA closure

Allow personal values and willingness to pay into the allocation decision

Rational Allocation of Cardiovascular Care

High level of certainty of benefit High level of certainty of no benefit Uncertainty Who benefits?; how much?

Not

• ffered

Publicly funded

Privately paid

Allow personal values and willingness to pay into the allocation decision

Rational Allocation of Cardiovascular Care

High level of certainty of benefit High level of certainty of no benefit Uncertainty Who benefits?; how much?

Not

• ffered

Privately paid

With tax credits offsetting reduction in public funding

Publicly funded

Declining physician and hospital reimbursement as uncertainty increases

Payment modulated by uncertainty

• Allows (requires) upholding of core values around publicly-funded universal

coverage for care that is clearly beneficial

• Acknowledges that personal values – “willingness to pay” – play an

important role in health care allocation decisions

• Introduces discretionary private spending – and withholds full public

spending – when there is less certainty of benefit and where allocation decisions are more value-dependent

• Can be done in a graduated way rather than the current all-or-none

criterion of “medically necessary”

• Provides incentives to both provider and patient to make health care

decisions that optimize value

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Thank you

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• 15 patients, age range 32 - 59

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Philanthropy in Canadian health care

• WASHINGTON, Oct. 3, 2012 /CNW/ - Donors to Canada's health care
• institutions increased contributions by $151 million last year, 12.5
• percent more than in fiscal year 2010. Cash donations and pledges in FY
• 2011 totaled $1.355 billion, according to the AHP Report on
• Giving-Canada issued today by the Association for Health Care
• Philanthropy (AHP).
• "It has been four long years since Canadian hospitals and health care
• systems were able to exceed the $1.337 billion raised through
• philanthropy in 2007. This had been the high-water mark for giving to
• health care institutions in Canada since the year 2000," noted Jory
• Pritchard-Kerr, FAHP, AHP regional director for Canada and executive
• director of Collingwood General & Marine Hospital Foundation in
• Collingwood, Ont.
• The improved fundraising in fiscal year 2011 primarily enabled Canadian
• hospitals and health care systems to pay for up-to-date equipment, which
• accounted for more than 53 cents of every donated dollar. Other
• important purposes for which donations were expended included funding
• construction and renovation projects (13.3 percent), providing resources
• for research and teaching (9.8 percent) and general operations (8.3
• percent).
• As in past years, more than 8 of every 10 donors were individual givers,
• who contributed almost 6 of every 10 dollars raised. Most such donors
• were from the health care institution's surrounding community, while
• persons with direct ties to the facility, such as patients, staff,
• physicians and board members, represented more than 37 percent of all
• individual donors.
• Slightly more than 1 in 10 donors was a business or foundation. Their
• contributions exceeded 3 of every 10 dollars raised.
• Rational Allocation of Cardiovascular Care

• http://www.theglobeandmail.com/life/health-and-fitness/as-

health-care-costs-soar-business-seeks-a- remedy/article577793/

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Medicine is sacrosanct, hallowed, a calling . . .

• But the $$$ it needs and spends liberally are not sacrosanct, hallowed or in any
• ther way special. They’re the same ordinary $$$ that pay teachers and pave roads

and reduce carbon emissions.

• We talk about market forces in health care but it isn’t a true market because the

party doing the buying isn’t the actual patient – it’s always someone acting as the agent of the patient BUT without an explicit contract between agent and patient

• Doctor – patient relationship usually refers to the professional relation, but what if it

referred to a business relationship where the patient pays the doctor directly without an intermediary

Rational Allocation of Cardiovascular Care

• allowing non-lawyers to own equity in law firms would reduce

costs and improve services to customers by encouraging law firms, many of which are still knee-deep in paper, to use technology and to employ professional managers—the kind of people who tend to expect stock options as part of their package—to focus on improving firms’ efficiency.

Rational Allocation of Cardiovascular Care

Rational Allocation of Cardiovascular Care