PMB Review Introductory remarks at Clinical Advisory

PMB ReviewIntroductory remarks at Clinical Advisory

Committee meetings

August and September 2009

Boshoff Steenekamp

REF Project Specialist

Process to date

• PMB Review workshops early in 2008

• 3 drafts of a PMB review consultation document

• Numerous stakeholder submissions on these drafts

Essential healthcare

• Essential healthcare is made up of critical and relevant services that are: – necessary to preserve or improve the health of an

individual;

– scientifically sound, cost-effective, and of good quality;

– if not available, will result in death or serious morbidity; and

– delivered in a timely manner.

Number of individuals involved

Cla

ims

cost

per

ben

efic

iary

Few Many

Low

HighClaims cost per

beneficiary

Ab

ove

-th

resh

old

ben

efit

s fo

r al

l PM

Bs

Bel

ow

-th

resh

old

ben

efit

s fo

r sp

ecif

ied

se

rvic

es a

nd

co

nd

itio

ns

Hig

h c

ost

eve

nts

co

vere

d t

hro

ugh

PM

Bs

(mo

stly

in h

osp

ital

)

CD

L an

d o

ther

co

nd

itio

ns

on

cat

ego

rica

l lis

t

Spec

ifie

dse

rvic

es

Day-to-day expenses on an out-of-pocket basis or paid from MSA

EDL

Frequently raised matters

• EDL inappropriate in current environment– The intention of the EDL list is not to limit medicine

use to drugs on this list, but simply to state that any of the drugs on the list must be covered from first Rand

• Exclusions: Annexure I– The intention is that these conditions should be

excluded within the specified setting, not a general exclusion

• Challenges– Constitutional rights, mandate of DoH & Council

Concurrent Processes impacting on revised PMB regulations

Number of individuals involved

Cla

ims

cost

per

ben

efic

iary

Few Many

Low

HighClaims cost per

beneficiary

Ab

ove

-th

resh

old

ben

efit

s fo

r al

l PM

Bs

Bel

ow

-th

resh

old

ben

efit

s fo

r sp

ecif

ied

se

rvic

es a

nd

co

nd

itio

ns

Hig

h c

ost

eve

nts

co

vere

d t

hro

ugh

PM

Bs

(mo

stly

in h

osp

ital

)

CD

L an

d o

ther

co

nd

itio

ns

on

cat

ego

rica

l lis

t

Spec

ifie

dse

rvic

es

Day-to-day expenses on an out-of-pocket basis or paid from MSA

Proposed Essential Care Package

NHI Process

Technical analysis of economic

impact, affordability

pricing, construct,

related reforms

Clinical Advisory

committees

Drafting of Regulations

Stakeholder comments

Governance Structure

STEERING

COMMITTEE

PROJECT

MANAGER

HEALTHCARE

INTERVENTIONSREF PRICING

Participative

Co

nsu

ltat

ive

Sources for consideration

• Existing PMB regulations

• Third draft of the PMB review consultation document

• Stakeholder comments on the consultation document relevant to the specific advisory committee

• Final submissions by committee members to the committee

Terms of reference

I. BackgroundII. Policy FrameworkIII. Composition of clinical advisory committees (CACs)IV. Criteria for evaluating a recommendationV. Role of the ChairVI. Code of conduct for CAC membersVII.Logistics

Annexure A: Clinical Advisory Committee agenda items, meeting dates, and relevant comments on the PMB review consultation documents

IV. Criteria for evaluating a recommendation

Submitted recommendations must comply with the principles of evidence-based medicine decision making and therefore it is crucial that sufficiently detailed information on how the evidence was obtained is provided. In addition, the criteria outlined below should be adhered to:

1. Clinical effectiveness2. Degree of discretion3. Urgency4. Cost-effectiveness/ economic evaluation5. The health benefits of the recommendation should be compared

with the next best available alternative treatment. If possible a balance sheet of the benefits, harms and major costs of recommendation should be itemised against those of the available alternative

Degree of discretion

Apply principles Apply principles Apply principles

Apply principles Apply principles Exclusion

Exclusion Exclusion Exclusion

Discretion

Med

ical

nec

essi

ty

Low Medium High

Low

Medium

High

The health benefits

• The health benefits of the recommendation should be compared with the next best available alternative treatment. If possible a balance sheet of the benefits, harms and major costs of recommendation should be itemised against those of the available alternative

Cost weight of the top six REF risk factors, December 2008

NON 51%

MAT 8%

HYP 7%

DM2 5%

HYL 4%

IHD 3%

HIV 3%

Other19%

CDL groups

Lifestyle diseases HYP, IHD, HYL, DM2

Other cardiac CMY, CHF, DYS

Multiple chronic diseases CC2, CC3, CC4

Psychiatric BMD, SCZ

Renal CRF

Respiratory AST, COP, BCE

Endocrine DM1, TDH, ADS, DBI

Neurologic EPL, MSS

Autoimmune RHA, SLE, CSD, IBD

Other HAE, PAR, GLC

Total REF risk factor cost load by CDL groupDecember 2008

0

100,000

200,000

300,000

400,000

500,000

600,000

700,000

800,000

R 0

R 20,000,000

R 40,000,000

R 60,000,000

R 80,000,000

R 100,000,000

R 120,000,000

R 140,000,000

R 160,000,000

R 180,000,000

R 200,000,000

Un

de

r 1

1-4

5-9

10

-14

15

-19

20

-24

25

-29

30

-34

35

-39

40

-44

45

-49

50

-54

55

-59

60

-64

65

-69

70

-74

75

-79

80

-84

85

+

NON Lifestyle diseases MAT Multiple chronic diseases

Other cardiac Respiratory HIV Endocrine

Renal Neurologic Psychiatric Other

Autoimmune Population

Cost pbpm of the REF risk factors by age and CDL groupDecember 2008

R 0

R 200

R 400

R 600

R 800

R 1,000

R 1,200

Un

de

r 1

1-4

5-9

10

-14

15

-19

20

-24

25

-29

30

-34

35

-39

40

-44

45

-49

50

-54

55

-59

60

-64

65

-69

70

-74

75

-79

80

-84

85

+

Axi

s Ti

tle

NON Lifestyle diseases MAT Multiple chronic diseases Other cardiac

Respiratory HIV Endocrine Renal Neurologic

Psychiatric Other Autoimmune


0

100,000

200,000

300,000

400,000

500,000

600,000

700,000

800,000

R 0

R 200

R 400

R 600

R 800

R 1,000

R 1,200

Un

de

r 1

1-4

5-9

10

-14

15

-19

20

-24

25

-29

30

-34

35

-39

40

-44

45

-49

50

-54

55

-59

60

-64

65

-69

70

-74

75

-79

80

-84

85

+

Axi

s Ti

tle




Autoimmune Population


0

100,000

200,000

300,000

400,000

500,000

600,000

700,000

800,000

R 0

R 200

R 400

R 600

R 800

R 1,000

R 1,200

Un

de

r 1

1-4

5-9

10

-14

15

-19

20

-24

25

-29

30

-34

35

-39

40

-44

45

-49

50

-54

55

-59

60

-64

65

-69

70

-74

75

-79

80

-84

85

+

Axi

s Ti

tle




Autoimmune ICR Population

V. Role of the Chair

The Chair of each of the CACs will be appointed by the Steering committee and will be briefed by the project manager on the scope of the project.The chair will:

1. Guide the task of developing final recommendations and the process thereof.

2. Assist the team to work collaboratively and effectively together ensuring that there is balanced contribution from all members.

3. Steer the discussion according to the agenda4. Summarise the main points and key decisions from the debate,

noting any points of disagreement.5. Sign off minutes compiled the secretariat.

VII. Logistics

1.Committee members must review the comments made by other stakeholders as listed in Annexure A and submit their final proposals at least seven days prior to the scheduled meeting.

2.The chairperson of each advisory committee must make final recommendations to the PMB Review Steering Committee by 29 September 2009.

Purpose of today’s meeting

• Consider the respective agenda items in view of

– Existing regulations

– Proposals made in the 3rd draft of the PMB review document

– Stakeholder comments on the 3rd draft

– Final submissions must be introduced by committee members

• No time for additional presentations or the introduction of new items

Summary of Oncology DTPs

Code Diagnosis Treatment

950A Benign and malignant brain tumours,

treatable

Medical and surgical management which

includes radiation therapy and chemotherapy

950B Cancer of the eye and orbit - treatable Medical and surgical management, which

includes radiation therapy and chemotherapy

950C Cancer of oral cavity, pharynx, nose, ear,

and larynx - treatable

Medical and surgical management, which

includes chemotherapy and radiation therapy

950D Cancer of lung, bronchus, pleura,

trachea, mediastinum &

other respiratory organs - treatable



952F Cancer of retroperitoneum, peritoneum,

omentum & mesentery - treatable



950C Cancer of the gastro-intestinal tract,

including oesophagus, stomach, bowel,

rectum, anus - treatable



950G Cancer of liver, biliary system and

pancreas – treatable

Medical and surgical management

950H Cancer of bones - treatable Medical and surgical management, which


950J Cancer of breast - treatable Medical and surgical management, which

includes chemotherapy and radiation

therapy

954J Cancer of skin, excluding malignant

melanoma - treatable

If histologically confirmed, Medical and

surgical management, which includes

radiation therapy

952J Cancer of soft tissue, including

sarcomas and malignancies of the

adnexa - treatable



therapy

953J Malignant melanoma of skin - treatable Medical and surgical management, which

includes radiation therapy

950K Cancer of endocrine system, excluding

thyroid - treatable



therapy

952K Cancer of thyroid - treatable; carcinoid

syndrome



therapy

954L Cancer of penis and other male genital

organ - treatable



therapy

953L Cancer of prostate gland - treatable Medical and surgical management, which


therapy

950L Cancer of testis - treatable Medical and surgical management, which


952L Cancer of urinary system including

kidney and bladder -

treatable



954M Cancer of cervix - treatable Medical and surgical management, which


952M Cancer of ovary - treatable Medical and surgical management, which


950M Cancer of uterus - treatable Medical and surgical management, which


953M Cancer of vagina, vulva and other

female genital organs NOS -

treatable



901S Acute leukemias, lymphomas Medical management, which includes

chemotherapy, radiation therapy, bone

marrow transplantation

910S Multiple myeloma and chronic

leukaemias

Medical management which includes

chemotherapy and radiation therapy

Structure of today’s meeting

• Introduction – CMS / DoH

• Agenda items

– Regulations, Third draft proposals, Submissions & Summaries

• Lunch

• Attendance list

THANK YOU

Documents

PMB Review Introductory remarks at Clinical Advisory