Australia's approach to health technology assessment is technically complex but, in principle, quite simple. It is about the government prioritising its need to achieve 'value'.
Value sits at the top of the government's hierarchy of needs.
It sounds fair enough but it does mean that when the government's decision-making framework considers funding treatments that alleviate patient suffering, or even save lives, what matters is achieving value.
Of course, value is a euphemism for financial considerations.
HTA systems seek to balance value and patient need. Yet balance can mean virtually anything to anyone because it is subjective. A patient's view of value almost certainly differs greatly from that of the government and its decision-makers, who prefer to operate in the 'averages' of population health.
Australia's HTA decision-making framework manages this subjectivity through contested but one-sided value assessments.
The government exerts significant power to secure value from its perspective because it can.
Companies make their submissions, and the government gets to work on its assessment. It is ridiculous to attribute any scientific merit to this process because it is one-sided and driven by financial considerations. It is a price negotiation involving one party with the power to impose its will.
How this power is exercised would be illegal in most other parts of the economy, but competition law does not apply to the government's administration of public health programs.
This is a simplification, but we live in a system where something might only represent value to the government in 2023 because it costs 25 per cent less than in 2022. In other words, the cost of treating and alleviating a patient's suffering in 2023 might only represent value to the government if the cost is 25 per cent lower than last year.
Nobody disputes the need to achieve value in public health program spending, but nobody should pretend that HTA processes deliver scientifically objective outcomes.
They are educated guesswork based on economic modelling that has been heavily manipulated by parties with a significant interest in achieving a certain outcome. Both parties in the value contest use modelling to achieve a particular outcome. It is just that one of those parties holds extraordinary power.
This, in essence, is our HTA decision-making framework.
It matters because the delays in access that are such a hallmark of Australia's HTA decision-making are an inevitable consequence of this framework.
In this context, it stands to reason that achieving the goal of faster access through the current HTA review will require the all-powerful government to agree to change its approach, unless anyone believes the solution implausibly involves more HTA processes and complexity.
A changed approach must mean the government taking a step back on how it uses HTA. Is that possible?
A good start would be some key performance indicators (KPI) over time to access. The only official KPI for PBS decision-making is listing within six months of reaching a pricing agreement following a PBAC recommendation. The goal is 80 per cent.
Yes, a $15 billion public health program has one official KPI, and it is administratively meaningless nonsense.
A real problem is the absence of policy innovation over an extended period. Is reform even possible within the current HTA institutional framework?
To be clear, submission pathways, pricing policies, different approaches to technical inputs and new processes are no substitute for actual reform or a proper strategic discussion about what we want as a community.
Unfortunately, the discussion rarely goes beyond closed-door HTA policy processes involving the same people, having the same discussion about the same issues.
Look at what passes for HTA policy discussions in 2023.
The HTA review is an example of a government-dominated HTA institution reviewing itself under a non-disclosure agreement.
Then there is the all-too-real scenario of a group of 'experts' spending several days discussing aspects of HTA in closed sessions. They then open the final day to the public to present the outcomes of those closed sessions.
This is not, and will never be, an appropriate way to develop or even discuss public health program policy. Frankly, the fact that anyone thinks this is a good idea says all we need to know about the problem.
In fairness, it is well-intentioned, but the fact this passes as an acceptable form of policy dialogue only provides further evidence of the fundamental malaise afflicting our HTA institution.
It signals a profound disconnect between the HTA institution and the community public health programs are designed to serve.
Recent comments by health minister Mark Butler have highlighted the urgent need for a new debate led by new voices.
Mr Butler described Australia's HTA decision-making as 'clunky' and responsible for delayed access to treatment and, ultimately, deaths.
It was a scathing but, importantly, simple deconstruction of decision-making. He appeared deeply uncomfortable at having to concede the reality of preventable deaths. Yet surely this is the KPI that matters?
His discomfort was the right response because how can we as a community be anything other than embarrassed and deeply saddened by these preventable deaths? How is it allowed to happen?
The HTA institution has responded with public silence. Even in its discussions behind closed doors, has it acknowledged the withering nature of Mr Butler's statements?
The minister's comments should lead to a broader national debate and self-reflection by our HTA institution.
How can anyone be comfortable being part of a system described by the health minister as responsible for preventable deaths? His statement might even be interpreted as having no confidence in the HTA institution.
Yet HTA decision-making in this country is now so institutionalised can it even respond to the utterly damning assessment of its most senior decision-maker? Time will tell, but what hope for patients if it can decide to ignore the minister?
