Breaking up is hard to do: why disinvestment in medical technology is harder than investment
Marion Haas A C , Jane Hall A , Rosalie Viney A and Gisselle Gallego BA Centre for Health Economics Research and Evaluation, University of Technology Sydney, PO Box 123, Broadway, NSW 2007, Australia. Email:jane.hall@chere.uts.edu.au, rosalie.viney@chere.uts.edu.au
B Community Based Health Care Research Unit, Faculty of Health Sciences, University of Sydney, PO Box 170, Lidcombe, NSW 1825, Australia. Email:gisselle.gallego@usyd.edu.au
C Corresponding author. Email: marion.haas@chere.uts.edu.au
Submitted: 11 April 2011 Accepted: 14 September 2011 Published: 25 May 2012
Abstract
Healthcare 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 healthcare 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 practice guidelines) and for implementing the disinvestment process (program budgeting and marginal analysis (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.
What 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 focusses 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.
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