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5th International EBHC Symposium 2010
“HTA & Health Insurance”
The Symposium which took place on 22-23 November 2010 in Cracow, in the Auditorium Maximum hall of the Jagiellonian University.
The EBHC Symposium, which was organized for the fifth time, is a unique educational initiative for participants from Poland and other Central and Eastern Europe countries. It is an opportunity of meeting experts from Europe and the whole world. It also gives a possibility to freely exchange opinions with representatives of ministries and health funds as well as European medical and business environments.
The main motive of 5th Symposium was the relation between health technology assessment (HTA) and modern systems of additional insurances. HTA is a basis for creating offers for complementary insurances competing on health services. Regardless of the effectiveness, safety and cost-effectiveness of treatment and diagnostic methods, it is hard to imagine a rational approach to creating policies comprising health services not included in the guaranteed services basket and/or, to which access within the basic contributions is limited. The precision of estimations within clinical, economical and financial analyses influences the risk connected to policy sales, and without a high quality HTA report the business risk of the insurer is huge. Uncertainty of estimations is inversely proportional to the risk of a given policy, and therefore it influences its price and market attractiveness. First policies of complementary insurances or mixed insurances: supplementary-complementary, as long as they will be developed on the basis of reliable analyses will become reference policies for further products on the market.


Schedule
The scientific program of the Symposium was presented over two days in six thematic sessions:
  1. Plenary session of the Agency for Health Technology Assessment (AHTAPol). Undertaking HTA with limited resources - Polish experience
  2. Justice and healthcare: Access limitations to basic medical benefits
  3. Justice and healthcare: Ethical basis of health care systems reforms
  4. Additional insurances in the evolution of health care systems
  5. The role of HTA in developing an insurance policy and additional insurance packages
  6. Watch Health Care (WHC) – a queue as a technology of proven harmfulness


Speakers
  • Prof. Steffie Woolhandler
    MD, MPH Professor of Medicine, Harvard Medical School Cambridge Hospital, Cambridge Health Alliance, USA
  • Prof. Daniel Wickler
    PhD, Mary B. Saltonstall Professor Professor of Ethics and Population Health Department of Global Health and Population Harvard School of Public Health, USA
  • Helen Chung
    MBBS, MSc, AIA, Associate Director - Appraisals, Centre for Health Technology Evaluation, National Institute for Health and Clinical Excellence, UK
  • Prof. Zbigniew Szawarski
    Institute of Philosophy, University of Warsaw, Poland
  • Prof. Henrik Wulff
    University of Copenhagen, Denmark
  • Wija Oortwijn
    PhD, Principal Health Consultant at ECORYS, The Netherlands
  • Wim Goettsch
    PhD, Deputy Secretary Medicinal Products Reimbursement Committee, Dutch Health Care Insurance Board (CVZ), The Netherlands
  • Wojciech Matusewicz
    MD, PhD, President of Agency for Health Technology Assessment in Poland, Poland
  • Anna Janczewska-Radwan
    President of the Board of POLMED, Poland
  • Prof. Michał Marczak
    Faculty of Health Science, Medical University of Lodz, Poland
  • David Danko
    Research Fellow, Institute of Management, Corvinius University of Budapest, Hungary
  • Paweł Kalbarczyk
    PIU, Poland
  • Xenia Kruszewska
    MD, PhD, President of the Board, MEDICA Polska Ubezpieczenia Zdrowotne TU SA, Poland
  • Tomasz Romańczyk
    MD, PhD, The Polish Chamber of Physicians and Dentists, Poland
  • Eva Turk
    MA, MBA, Institute of Public Health of the Republic of Slovenia, Slovenia
  • Adam H. Pustelnik
    PhD, President of the Board, Signal Iduna Poland Insurance Company S.A., Poland
  • Joanna Lis
    PhD, MBA, Manager of Health Economics Dept. Sanofi-Aventis Group, Poland
  • Halina Kutaj-Wąsikowska
    I Deputy President of Polish Society for Quality Promotion in Health Care, member of ESQH, Poland
  • Marek Labon
    MD, former President of Polish Society for Quality Promotion in Health Care, Medical Advisor to the Municipal Hospital in Gdynia, Poland
  • Krzysztof Łanda
    MD, President of the Board, Watch Health Care Fundation, Poland
  • Magdalena Władysiuk
    MD, MBA, President of the Board of the Central And Eastern European Society of Technology Assessment in Health Care (CEESTAHC), Vice-president, HTA Consulting, Poland


Sessions
1. Plenary session of the Agency for Health Technology Assessment (AHTAPol). Undertaking HTA with limited resources - Polish experience
During the plenary session the latest Polish achievements in the field of Health Technology Assessment will be presented. The Polish road to the establishment of a HTA agency was on the one hand fairly “intricate”, on the other hand the process was very dynamic, as it was the case with other countries of our region. Until August 2009 the Agency acted under the Minister of Health’s order of 2006 and it dealt mainly with issuing recommendations for medical technologies commissioned by the Ministry of Health. Due to the fact that the Agency was called by way of an order, an internal and therefore a lower rank normative act, its role in the system was rather vague, and the functions and tasks, as it has been underlined by many experts, was too dependent on the will of the Ministry of Health. A HTA agency’s key to success is nevertheless its independence from the changeable will of decision makers. Changing the legal status of the Agency which became a legal entity by virtue of the Act of 25 June 2009 amending the Act on health care services financed from public funds and the Act on prices was an unquestionable success. The authorization of AHTAPol in the health services system in Poland by way of an act has significantly strengthened the Agency’s role and tasks.
The plenary session dedicated to AHTAPol will allow for a presentation of the Polish road to a HTA agency, with underscoring of its current tasks and achievements, including also those in the arena of international politics. Polish experiences will be confronted with experiences of other countries from our region and from countries which have already accomplished this task. An important element of the session will be a comparison of tasks and achievements of the Polish agency with solutions from other countries, where a different functioning model of the HTA agency has been adopted (especially the so-called heavy model, such as HAS or NICE).
2. Justice and healthcare: Access limitations to basic medical benefits
3. Justice and healthcare: Ethical basis of health care systems reforms
Our health needs grow much faster than possibilities and means allowing for their satisfying. There are several reasons for that: (1) we live longer (2) due to unsuitable environmental conditions and lifestyle the number of recognisable and treated diseases grows (3) technological development in medicine provides newer and more expensive diagnostic and therapeutic methods and measures all the time. The general health insurance does not suffice to guarantee every citizen direct and simple access to health care. Due to the fact that costs of public health care, as well as diagnosing and treating diseases are constantly growing, no country, even one which is most economically developed is not able to guarantee its citizens the satisfaction of all possible individual health care needs.
In such a situation there is a need to univocally define the principles of just distribution of the limited health funds. If it is impossible for us to successfully satisfy all of the citizens’ health care needs, we not only have to define who deserves what (guaranteed services package) and what are the limitations of treatment, but we also have to morally justify our choice of these principles of the limited resources’ distribution.
4. Additional insurances in the evolution of health care systems
In former times people possessed money, but medicine did not have much to offer. Often the “medical technologies” used in the previous centuries were ineffective, bordering on magic and beliefs or even harmful. Today one can spend any amount of money on health care and no country can afford to finance the most effective medical technologies in every indication. It is said today that medicine’s possibilities have exceeded financial possibilities – therefore the famous statement of the late Professor Zbigniew Religa, that in Poland, within the funds of basic contributions “we treat all diseases, but not with all methods”. In the past times access to doctors and treatment was a privilege of the rich, and the poor used the advice of quacks or they were not treated at all. When a Bismarckian security system was developed, medicine was used by a much wider group of people, from the poorer social classes. Many scientific works indicate that even a modest health insurance for a low contribution is socially better than no such insurance at all – take the example of Rwanda, were for 7 USD of yearly health contributions the insured receive access to a few most important health services in the basic package. The wealthiest countries usually do not have problems with providing access to basic and most important health services – they simply can afford much. In wealthy countries there are supplementary insurances, but often also complementary insurances, offering relatively few health technologies which are not included in the guaranteed package. On the other hand, probably the majority of moderately wealthy and developing countries have disproportions between the contents of the “guaranteed” benefits package and the amount of funds from basic contributions. This disproportion gives rise to various pathologies, among others: queues, corruption or using privileges in access to doctors. Eliminating disproportions between the contents of the guaranteed benefits package and the amount of funds from basic contributions can be achieved in 3 ways, that is: 1. Increasing the basic contribution for the insured or the “health care tax” in the security system, 2. Eliminating expensive and least cost-effective technologies from the guaranteed package or 3. Allowing for a development of additional insurances in the field of health services which are not covered from the basic contributions. It seems that solution 1 is difficult to perform from the political point of view and solution 2 is simply impossible from the political point of view. Therefore one is left with solution 3, and therefore the development of additional complementary insurances competing on health services, to which access within the basic contribution is limited in a given country.
5. The role of HTA in developing an insurance policy and additional insurance packages
Health technology assessment plays a very significant role in the development of health insurance policies, both in the case of a payer’s monopsony in the security system, as well as in the case of market play of insurance institutions. In the first case, it is very important for the payer and politicians to maintain financial discipline, but it should also be important to secure proper access to health services which are most significant from the point of view of society’s health, and therefore highly effective and most cost-effective from the available options. In the case of market play of insurance institutions, regardless of the level in which it occurs, HTA provides basic information which is necessary for actuaries to assess the risk of particular policies. Without information obtained due to health technology assessment it is very difficult to reach the golden mean, that is achieving a business success and at the same time creating an offer which would be attractive for clients. HTA is a basic tool used for the purpose of developing the basic benefits package in developed countries, however, in the case of developing a nonstandard or negative package the role of health technology assessment reports is even greater and the process of assessment more strict – examples of painful lessons resulting from lack of exact/careful justification of exclusions have been already presented on one of the earlier CCESTAHC Society’s Symposiums. In case of a nonstandard package, which is used by complementary additional insurances competing on health services, HTA is of key importance, both with reference to principles and practice of developing such a package, and therefore the attractiveness of its contents for potential clients, as well as with regard to the development of policies itself.
6. Watch Health Care (WHC) – a queue as a technology of proven harmfulness
Watch Health Care (WHC) Foundation was registered on 2 April 2010 in Cracow. The mission of the Foundation is providing broad, competent, credible and evidence-based information on the disproportion of financial means and the contents of the package and the limitations of access to health care in Poland. This information is directed at: decision makers in health care, patients and healthy people and additional insurance institutions. The collected information regards limitations in access to health services as seen by the patient, and therefore depicts the patient’s often sad reality. The most often reported types of access limitations are as follows: queues, reducing services by way of limiting the size of the contract with the National Health Fund, undervalued (erroneous) evaluation leading to selecting patients, stepwise treatment and red tape, narrowed down criteria of including to therapeutic programs, copayment, lack of procedure standards and others. Limitations of access to services included in the “guaranteed” package are presented in the form of a ranking. In this field the main criterion is cost-effectiveness - the relation of cost to the received health benefit. Additional ranking criteria comprise: influence on public health, influence on the patient’s health, effectiveness/strength of an intervention, the degree of difficulties resulting from limited access, the importance of the number of service providers and the uncertainty of estimations towards the cost-effectiveness. There are also presented services which are not included in the guaranteed package, that is services which currently are not financed from basic contributions in Poland. In this field the main ranking criteria is the advantage in the strength of an intervention compared to the other most effective treatment option, that is efficacy. Other criteria are: impact on public health, impact on the patient’s health and the uncertainty of estimation towards the strength of an intervention.


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