Changing the way we make decisions
Consequences for the health system
If the medicine or medical device was funded, what would be the consequences for the health system?
PHARMAC’s decisions can have flow-on impacts for the rest of the health system. For example, if support services are required to administer a new treatment.
The health benefit to family, whānau and wider society
What would the health benefit be for the family or whānau of the person receiving the treatment, and for wider society?
A medicine or medical device may have health benefits beyond the person receiving the treatment. For example, reducing antibiotic resistance will have positive health benefits for all New Zealanders.
The health benefit to the person
What would the health benefits be to the person who would receive the medicine or medical device that is being considered?
We consider, for example, if the treatment will make the person healthier, or help them live a longer life.
Costs and savings to pharmaceutical expenditure
How would the funding of the medicine or medical device impact on pharmaceutical expenditure?
Would funding this medicine or medical device result in some savings due to people switching from another pharmaceutical that is already funded?
DHBs have limited funding available for pharmaceuticals used in the community or in hospital,, so we need to consider the health outcomes that can be achieved from the limited amount of money available.
Costs and savings to the rest of the health system
Would the funding of the medicine or medical device create costs or savings for the rest of the health system?
Funding medicines or medical devices can have flow-on impacts for the rest of the health system (the health system refers to New Zealand’s health and disability system). For example, if a treatment can be given at home rather than in hospital it would free up a hospital bed for someone else to use.
Health-related costs and savings to the family, whānau and wider society
What would the health-related costs and savings be to the family or whānau of the person receiving the medicine or medical device, or to wider society?
Funding a medicine or medical device may result in health-related costs and savings to family and whānau of the person receiving the treatment. For example, family and whānau may be caregivers, and a treatment may reduce the need for the level of care and the costs associated with this.
Health-related costs and savings to the person
What would the health-related costs and savings be for the person who would be treated with the medicine or medical device that is being considered?
We consider costs and savings for the person receiving the medicine or medical device; for example, the amount a person pays for a GP visit to be able to access the medicine or medical device.
The features of the medicine or medical device that impact on use by the health workforce
What features of the medicine or medical device may have an impact on use by the health workforce?
How the health workforce uses the medicine or medical device may affect the health of the person, for example, a medicine that is easy to use may reduce the likelihood of error or accident.
The features of the medicine or medical device that impact on use by family, whānau and wider society
What features of the medicine or medical device may have an impact on use by the family or whānau of the person receiving the medicine or medical device, or wider society?
When family, whānau or members of wider society are the primary caregivers of a person receiving a medicine or medical device, the features of the medicine or medical device may affect their ability to administer the treatment. This in turn may affect the person’s health outcomes. For example, it may be easier for caregivers to give a sick person a pill than to give an injection.
The features of the medicine or medical device that impact on use by the person
What features of the medicine or medical device may impact use by the person receiving the medicine or medical device?
We may consider non-clinical features such as the size, shape and taste of a medicine, or its method of delivery (e.g., oral vs injection) that may affect health outcomes. For example, if a capsule is very large, some people may not be able to swallow it. This could affect their health outcomes.
The impact on Government health priorities
Is the disease, condition, or illness a government health priority?
The Government chooses some health problems for the whole health sector to focus on. The current health priorities can be found in the Ministry of Health’s Statement of Intent, PHARMAC’s Statement of Intent, Output Agreement and/or Letter of Expectations.
The impact on the Māori health areas of focus and Māori health outcomes
What is the impact of the disease, condition or illness on Māori health outcomes?
Has the disease, condition or illness been identified as a Māori health area of focus in our Māori health strategy Te Whaioranga?
PHARMAC is committed to improving the health outcomes of Māori and being a great Te Tiriti/The Treaty partner. We work with Māori to identify specific health areas that are important to Māori communities.
The impact on the health outcomes of population groups experiencing health disparities
What is the impact of the disease, condition, or illness on other population groups, including Pacific peoples, already experiencing health disparities?
This Factor enables us to consider the impact of a decision on the health outcomes of Pacific peoples, and other population groups that are facing health disparities as a result of an underlying disadvantage, separately from the illness itself. They may be characterised by ethnicity, culture, location, or socioeconomic status.
The health need of the person
How unwell is a person compared to the average healthy New Zealander?
One major way in which we consider this is by comparing life expectancy and quality of life at full health and with the disease, condition or illness.
The availability and suitability of existing medicines, medical devices and treatments
What options are currently publicly funded for a person with this condition?
How well do the current options work compared to the new option?
The alternative options could include treatment in a public hospital or in the community with a medicine, medical device or a treatment such as physiotherapy.
What is changing? PHARMAC is changing the way we make decisions by introducing the Factors for Consideration.
When is this taking effect? From 1 July 2016 we expect that all decisions will be made using the Factors for Consideration.
PHARMAC is embarking on one of the biggest changes in its 21-year history – changes to the way it makes decisions. This includes decisions about which medicines and medical devices will be funded.
From late 2015, PHARMAC will move to the following Factors for Consideration, a shift away from the Decision Criteria that have served us up until now.
Does the proposal or decision help PHARMAC to secure for eligible people in need of pharmaceuticals the best health outcomes that are reasonably achievable from pharmaceuticals treatment and from within the amount of funding provided
This interactive tool is designed to make it easy to learn about the new Factors we will use when making funding decisions from late 2015. Hover over each section to reveal more information about each Factor.
PHARMAC is the Government agency that looks after the management and funding of medicines and medical devices that many New Zealanders use and need. At the moment PHARMAC uses 9 decision criteria. Things are changing, PHARMAC’s role is expanding and we need to take account of what the public think about PHARMAC’s decision-making. So, we ran a series of community forums to get the public’s view directly. It was really great that so many people came along and contributed and were able to discuss these matters with us in person because that provided us with a really good view of what people felt our decisions meant to them.
So we wanted to be really thorough and we created a prototype that we then went back out and tested with people and the public. And as a result of that and as a result of the feedback we got, we’ve now made the biggest change in PHARMAC’s 21 year history as to how we got about making decisions.
And to help ensure that these Factors are really clear, we’ve developed a diagram which outlines the Factors for Consideration.
In the centre of the diagram is our statutory objective. This is the main thing that PHARMAC’s trying to achieve.
The Factors ultimately guide us to achieve the best health outcomes for all New Zealanders.
We’ve grouped the Factors into four main dimensions of the circular diagram. These are:
- health benefits
- costs and savings
There are also three levels of impact that we take into account. These are:
- to the person
- to family/whanau/wider society
- to the wider health sector
Let’s take a closer look at each dimension.
The first one is the need dimension:
- The health need dimension is about the disease or illness.
- When we think about the impact the disease or illness has on the person we think about how unwell the person is compared with the average healthy New Zealander. We also must also consider what funding options may already be available to treat the illness in question.
- In considering the impact on family/whanau and wider society we will think about the impact the illness has on Maori, and also other population groups, including Pacific people facing health disparities.
- We will also consider need at the health system level as reflected by government health priorities.
The health benefit dimension:
- This dimension takes into account whether the medicine or medical device may extend or improves their quality of life.
- We also look at whether treating the individual can have benefits for the wider population. For example, with antibiotic resistance. If that’s reduced that’s good for everybody. And vaccination, reduces the spread of diseases.
The costs and savings dimension:
- We will think about the health-related costs and savings for the person and their family, whānau and to wider society.
- The costs and savings to the health system cover both the pharmaceutical budget and the wider health system.
And, finally, the suitability dimension:
- The suitability dimension looks at features of a medicine or medical device.
- We may consider things like the size, shape and taste of a medicine that may affect health outcomes.
- This dimension is also where we would we consider the suitability of medical devices. For example, where more sensitive medical gloves will be better suited to finer work.
- We may consider things like the size, shape and taste that may affect a person taking their medicine.
- Suitability could look at whether a change in a medicine could reduce the likelihood of error or accident by primary caregivers (family/whanau) or even the wider health workforce.
The Factors are designed to make the things PHARMAC may take into account for a decision more explicit and more transparent and to support our expanding role.
You can find more information about the Factors for Consideration on our website at www.pharmac.govt.nz .
We’re making this change to reflect feedback we’ve received about how we make decisions, and also to ensure our process fits all our work, including medicines, vaccines and medical devices. The long lead-in time is to help us and our stakeholders adapt to the change, and we’ll be communicating with our stakeholders throughout the implementation process.
The pathway to change
Over the past few years PHARMAC has been reviewing how we operate. At the same time, our work has been expanding into new areas. This has led us to look at the way we make decisions, and ask if this needs to change to better reflect the wider work we are now involved in.
We also thought it would be a good idea to get the public’s views so we ran a wide-ranging and lengthy consultation process through 2013 and 2014.
In 2013 we asked people what criteria or factors they thought should be considered when PHARMAC makes decisions. We ran 12 community forums throughout the country, which were attended by more than 300 people. The many ideas and viewpoints put forward at these forums, plus the more than 130 written submissions we received, formed the basis for a draft set of factors we consulted on in early 2014.
This second consultation also involved considerable public input, and we held a consultation event in Wellington in April 2014 to start this process.
Anticipated timeline of the transition from the Decision Criteria to the Factors for Consideration.
- 17 August 2015 – Release of the updated Guidelines for funding applications to PHARMAC, Prescription for Pharmacoeconomic Analysis and CUA Explained.
- February 2016 – Applications to be considered at the May 2016 PTAC meeting are to be submitted by February 2016 with reference to the updated Guidelines for funding applications to PHARMAC.
- May 2016 – PTAC will make its recommendations to PHARMAC using the Factors, rather than the Decision Criteria.
- 1 July 2016 – Funding decisions made by PHARMAC will use the Factors for Consideration from this point on.
PHARMAC is always willing to consider new information relating to funding applications on which decisions have not been made. We would make decisions about those applications from 1 July 2016 using the Factors for Consideration, and suppliers may wish to provide us with new information about applications currently before us in light of the Factors.
Note: applications for consideration at the November 2015 and February 2016 PTAC meetings will be considered against the Decision Criteria.
Last updated: 25 May 2016