Breaking up is hard to do: why disinvestment in medical technology is harder than investment

Abstract

Health care technology is a two-edged sword-it offers new and better treatment to a wider range of people and at the same time is a major driver of increasing costs in health systems. Many countries have developed sophisticated systems of Health Technology Assessment (HTA) to inform decisions about new investments in new health care interventions. In this paper we question whether HTA is also the appropriate framework for guiding or informing disinvestment decisions.In exploring the issues related to disinvestment, we first discuss the various HTA frameworks which have been suggested as a means of encouraging or facilitating disinvestment. We then describe available means of identifying candidates for disinvestment (Comparative Effectiveness Research, clinical practice variations, clinical 2 practice guidelines) and for implementing the disinvestment process (PBMA and related techniques).In considering the possible reasons for the lack of progress in active disinvestment we suggest that HTA is not the right framework as disinvestment involves a different decision making context. The key to disinvestment is not just what to stop doing but how to make it happen-that is decision makers need to be aware of funding disincentives. 3 Key Question SummaryWhat is known about this topic?Disinvestment is an increasingly popular topic amongst academics and policy makers.Most discussions focus on the need to increase disinvestment as a corollary of investment, the lack of overt disinvestment decisions and the use of a framework based on health technology assessment (HTA) to implement disinvestment. What does this paper add?This paper focuses on the difficulties associated with deciding which technologies to disinvest in and the problems in using an HTA framework to make such decisions when disinvestment involves a different decision making context from that of investment.What are the implications for practitioners?The key to disinvestment is not just what to stop doing but how to implement such decisions. Making it happen means being aware of funding disincentives.

Priority-setting and rationing in healthcare: Evidence from the English experience

“…This approach was chosen to reflect the current focus on disinvestment and service redesign in light of the recent fiscal challenge (Robinson et al, 2011b). Given the wider literature is relatively silent about disinvestment (Elshaug et al, 2008;Robinson et al, 2011b;Hass et al, 2012;Williams et al, 2012), we sought exemplars to identify findings on these topics Case studies were undertaken in two phases. Initially, two case studies were selected for a detailed consideration of priority-setting in terms of the full range of activities conducted in this locality.…”

Tackling disinvestment in health care services

“…This requires information, analysis and local intelligence and in order to be successful requires the backing (or at least acquiescence) of stakeholders (Ham 2003;Greenhalgh et al 2009;Watt et al 2012) . An important source of support identified in the research could be clinical champions, however, as has been noted by commentators such as Haas et al (2012), they will not be effective in supporting disinvestment if wider structural incentives are not in place. In addition to information and stakeholder support the other key requirement of successful service redesign is project management (Greenhalgh et al, 2009), which may itself be in short supply in a context of fiscal retrenchment.…”

“…Furthermore, Haas et al (2012) suggest that, internationally, there is a gap between application of the HTA process to identify disinvestment opportunities and the process of actually disinvesting in these technologies; this implementation gap mirrors the difficulties that have been reported in implementing PBMA (Henshall et al 2012). They discuss incentivising patients and clinicians to follow HTA recommendations and thus increasing the possibility of freeing funding from outdated or ineffective technologies.…”

“…They discuss incentivising patients and clinicians to follow HTA recommendations and thus increasing the possibility of freeing funding from outdated or ineffective technologies. Examples of incentivising behaviours include the Quality and Outcomes framework in the UK which financially rewards GPs for delivery against specific indicators (Doran et al 2008) or the use of performance information to aid patient choice of provider in the US and ensure that providers prioritise quality and innovation (Haas et al, 2012). The use of decision aids amongst patients has been shown by O'Connor et al (2007) to not only increase the value of clinical interventions but also to reduce the use of interventions which patients perceive as being of little value.…”

Prioritering, styring og likebehandling: Utfordringer i norsk helsetjeneste

“…Når teknologien først er anskaffet, ser det med andre ord ut til at vi må avfinne oss med den. I litteraturen omtales dette ofte som disinvestment-problemet (Haas, Hall, Viney & Gallego, 2012;Henshall, Schuller & Mardhani-Bayne, 2012). Dette skaper utfordringer for prioritering, fordi teknologien legger beslag på ressurser som har alternativ anvendelse (alternativkostnader).…”