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0:06
hello and welcome to chat gcp a medical science clinical research and commercialization podcast and I'm your host Charles Beasley on today's episode we have Matt NM a market access professional you might be asking what is market access well Market access is the discipline by which the argument is made to payers whether that be the healthcare system in the case of universal healthcare or insurers for the reimbursement of a product being at a
0:30
medical device or pharmaceutical Market access is vital in order to get registered products to a patient and these activities ensure that our patients get access to the most coste effective solutions for their conditions on another note today's episode is brought to you by sapro your clinical trial pathway partner every clinical trial is unique and the most effective solution is to engage in a distinguished and highly experienced project consultant who can
0:59
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1:27
with their team of experts and their highly reputable Alliance Partners check out the links to sap Pro services and the show notes below but now friends please Welcome Matt [Music] [Applause] [Music] need all right so let's get straight into to it um Can Market access so that's that's your bread and butter that's what you do in your in your role at Ro um for the uninitiated uh what does Market access really mean and um maybe further to that how do
2:11
you get into that role yeah yeah absolutely I me I probably just want to mention up front I guess I I I do work for a um biopharmaceutical firm but I'm I'm just not sort of here representing their their views or their opinions I'm I'm sort of here talking about my own experiences but yeah Market access that's the the role that I've kind of cut my teeth on over the last kind of 10 years in in
2:31
in New Zealand and and Australia predominantly um how does one get into Market access it's a what when I was when I was starting out there was there was probably not the kind of like the direct University degree to job kind of pathway for for health economics and and um Market access like it was it was a discipline certainly and and there were there were already countries adopting sort
2:55
of Health technology assessment and these sorts of Concepts but it probably wasn't very certainly in my experience widely known as a discipline and so I like many of my colleagues um kind of got into it a bit sort of serendipitously or indirectly I guess I um I ended up doing an internship at a at a smaller uh biotch company in in Sydney at the end of my my degree and um that was originally a marketing project actually and I sort of sort of ser yeah in parallel realized that
3:25
perhaps marketing was not something that I really felt passionately about but I I was just hanging around the office a lot it was I was in Sydney I was I was you know in my early 20s and I didn't really know a lot of people so I just would just hang out there and and and chat to people and and get a bit of a feel for what the industry was about and one of the people who I I spoke to a lot was their their Market access director and and this kind of idea of of mixing business and
3:50
economics and and that kind of disciplines with the science and the kind of the the evidence the comparative effectiveness evidence and things like that really kind of appealed to me I thought that was really interesting and so I um did a bit of work with with her over the over the sort of six months that I was there and then um out the back of that started working at a consultancy doing um
4:11
assessments for medicines to be submitted to the Australian government who follow a sort of what we call a health technology assistant assistant framework which um abas you're your kind of your first your first guest first episode you know spoke very very um well and sort of clearly about what you know the concepts of health economics and and um cost benefit analysis and things like that
4:31
and so that that's a that's a big piece of it and um yeah that's kind of how I got started I kind of learned on the job as as you sort of tend to do um and it's just grown it's just kind of grown from there yeah amazing it's almost as like ubiquitous that the story and in a lot of you know Clinical Research Medical Science commercialization people just kind of fall into their various disciplines
4:52
and we not like made aware of all the different you know slices of roles that you can get into that all part that are all part of this ecosystem to bring you know novel science into a a product and then into a patient the other end like it's it's all actually all interconnected I've said this before but initially I was just going I mean chat gcp that kind of really strongly suggests it's just clinical research but I made the realization that like man it's actually all
5:17
interconnected you can't have strong clinical research without having good medical science and you can't have you know patients getting access to the new stuff without people like yourself in the middle you know once the drug is um ready to go the medical device is ready to go so essentially Market access is about making sure that a patient gets access to a drug or medical device at the right time right price you know absolutely yeah so I mean I guess there's
5:41
there's different systems around the world and and different kind of questions or or ways in which a medical technology Health technology can get to its get to patients I think in in a lot of countries New Zealand is a good example where we have a what we would kind of call a universal healthcare system where the the government is really responsible for investing in in health services and that includes devices and and and medicines um in order to provide to sort of
6:06
heavily subsidize those or to make those almost free of charge for for patients and so that's kind of the when we talk about Market access in a in a in a country like New Zealand that's really what that means it's about it's about making a an investment case to the payer so the the government and in in New Zealand's case that's predominantly farac for medicines it's tiat or uh the hospital d for for other Health Technologies often but it's yeah it's it's about kind of going
6:33
along and and presenting a body of evidence that shows that against what is current standard of care this new intervention has delivers some level of benefit yeah um and that then from those benefits we we sort of go through a process that about very clearly articulated around valuing putting a value to that to that benefit and then out of that falls often you know what what is the appropriate kind of price level for that for that intervention and and then you have a bit
7:01
of a discussion around well is that good value for money against other potential Investments that you can make is the budget impact of that investment affordable and then though if those two questions are yes then we're happy days we're away yeah so there's kind of two steps right because there's the registration of the drug or medical device and then there's the actual like you mentioned the the approval to fund it yeah you know so just because something is registered doesn't
7:25
mean automatically a patient gets access to it um particularly in universal healthcare system maybe if it's registered and it's commercially available via the the sponsor and you got deep Deep Pockets in many cases that's fine or you got a health insurance that's fine but often there's a there's a bit of a delay between registration and then actually the funding side of things in the case of universal healthcare systems like New Zealand and elsewhere absolutely yeah and
7:48
I mean you're absolutely right I mean for once a regulator has approved a technology or medicine it's it's available in the country and can be purchased uh privately often that is is um unaccessible to to most people particularly for um conditions that either are rarer or um have higher cost therapies associated with them so cancer I guess is a good example of that where the the treatment costs are prohibitively high for for most people and so really it's about making
8:18
those uh investment decisions as a as a government to make those treatments available to the widest possible proportion of people yeah right and what's the process like in New Zeal I mean we talked in Broad Strokes with abis in the first episode um of like the general types of Health technology assessment um um mechanisms that you have so like cost minimization um cost utility cost benefit um there's another one in there that that is uh eluding me um there's lots of different
8:46
typ um but those are the four kind of main big um categories but how does it strictly speaking in New Zealand what's the standard approach that you would take you kind of do a business case and you present it to pharmac or whatever the other pay might be to F order um and I and I imagine there's a lot of discussion that goes on back and forth yeah yeah absolutely so yeah so in New Zealand
9:10
uh the kind of the role of of evaluator and payer is played by by pharmac for medicines and for for a range of different agencies depending on what the health technology is for for other things for I mean my experience mainly is in medicines and so we can probably talk about pharmac as as a probably an example of that but essentially the the beginning of the process is that the the sponsor or the the the company um collate all of the the evidence that they have to show that there
9:38
is a particular clinical benefit um or a patient relevant benefit to this particular intervention and ideally you would be able to compare directly that new intervention with the relevant standard of care in New Zealand and so that's not always the easiest or always the case that you would have a direct head-to-head clinical trial in that in that with that particular comparison but there are ways to get around that if you don't you know you can make um indirect comparisons via
10:06
common comparators and things like that so there's more technical aspects of how you would go about that but really that's that's the kind of the basis for an application and it sort of follows a an acronym that um is sort of common in in our space called Pico which is basically describing who the population is that's going to receive the intervention so that the patient group what the intervention is so sort of go through a bit of a um discussion on the mechanism of action the
10:32
biological plausibility for why you would expect the results that you see in the clinical trial the comparator so what would you what are you going to be substituting or replacing in clinical practice and then then the outcomes so what what are the the clinical benefits that your or your patient benefits that your intervention is going to deliver and and are those important are they meaningful for the for the patient or for the healthare system and you sort of go through a
10:57
process of developing all of that and synthesizing that into a kind of a not always concise dossier that describes as much as well as you can from the evidence that you have um a sort of a summary of of why you would want to invest in this particular intervention I guess that's what you're trying to get to really yeah so really really does cross the boundary between science economics um medical
11:22
writing business case a bit of marketing all into one absolutely so you're jack of all trades yeah well you sort of I mean yeah you just sort of to be and to be fair like um we're not I'm I'm not an island in my company like so I we work ac across the different disciplines so I I'm not just kind of left alone in a in a dark room just to develop these sort of things like it's a it's a
11:43
it really is a team effort and so it does draw but you're abely right it draws on every aspect of of certainly of a commercial operation like ours to to describe um all of those different pieces in in sort of a concise way um yeah yeah that's super interesting I mean um we uh pharmac has has has often lorded as you know having being incredibly important and well tasked um organization um it
12:12
was established in the '90s right that's right um maybe we can talk about the history of pharmac and why it was put in place um and then maybe follow it through time because obviously we uh we've gone from a a previous guest referred to as medicine 1.0 2.0 and 3.0 like medicine 1.0 like medicine of your you know 1800s and before um and then we've got like wion 2.0 which is our you know small molecule being blasted out to Big populations and then medicine 3.0 really
12:42
leverages unique genotypes or phenotypes or what have you unique markers for a for a more targeted um delivery so that's your personalized medicine and precision medicine but kind of getting lost in the weeds here but maybe we can talk about you know um in in New Zealand specifically because it's quite interesting farac was set up to solve what kind of problem yeah so I mean in the it was set up in 1993 I believe I think early 90s and really it was established because there was a
13:11
view that I think as a small Market as a small country like newon we were um not able to use Market power to to get good prices for medicines I think was the kind of the view internationally and so there was a kind of a view that that over over time our our expenditure on on Pharmaceuticals was growing at a very rapid rate and so we needed to uh introduce some kind of balance to the system
13:37
that would that would try and prevent the rapid continued rapid growth of that and so pharmx remit really when they were established was to deliver the best health care outcomes for new zealanders but within a fixed amount of money so within a c a CA budget and they introduced a number of measures at that sort of that time that were really focused on Cost Containment and ensuring that the it gave the the payer farac as much power as they could really have to to ensure that the
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prices that we were paying for these medicines was was um value for money as as we saw it good value for money and so there are a number of things that they they did with that they obviously they fixed the amount of money that farac had to spend and so once they reached that cap that was as far as they could go they also uh introduced number of measures U sort of Market measures like uh
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granting single suppliers sort of Monopoly over over a particular um disease area or supply of a particular product um which enabled you know to play off different suppliers against each other and to sort of Drive comp prices down through competition in that way see um they also would regularly tender for supply of particular areas so um basically using using Market competition I guess really to to ensure that prices were as as low as possible um and that to be fair
15:05
I mean it's been very very effective like we we uson probably for the out Health outcomes that we deliver from the amount of spending or funding envelope that that farac operate in we're they're doing remarkably well um I guess the uh the challenge over time is that the the world as it was in the kind of the '90s and probably the early 2000s in terms of medical technology as you alluded to was you know population-wide treatments uh things cardiovascular disease and diabetes that
15:35
were small molec medicines with a low cost of of development low cost of manufacturer sorry the cost of development is still very high but low cost of manufacturer and really the idea being that um there was there was ability to to kind of control the costs in that kind of space you know if you're delivering a a high volume low cost medicine that's that's still very attractive to to suppliers and so that the model works I think what we've seen a shift from
16:03
the that period in in the90s to the kind of the late 2000s where you sort of there saw the rise of uh targeted therapy of sort of personalized Healthcare as a concept you know the the early um molecular Targets in like leukemia and blood cancer and things uh really kind of changed the game a little bit and it it changed the game in in the sense of the the types of outcomes that we could see in in cancer you know we went from um you know very system particularly in cancer sort
16:37
of systemic chemotherapy as the kind of the gold standard to targeted therapy and all of a sudden like the the survival outcomes just were just astronomical they they the the Improvement was was huge but at the same time the you know the more targeted the therapies that the narrower the the patient population who could benefit from those and so the the economics of of the the of the process changed a little bit in that way as well yeah um we were kind of just talking about
17:03
it before but essentially the the the cost of the the overall development cost to a to a supplier hasn't really changed over time if it's probably grown but as treatments become more targeted and populations become more narrow the the ability to to return that investment in in a once the drug is is sort of approved and out in the wild is has has become harder so to to meet that kind of those cost and that development need the the prices have had to rise and so that's what I kind
17:36
of mean by the the economics has really changed you've got a now you've gone from a lowcost high volume kind of world into a into a low volume very high cost world that that is delivering better outcomes but for smaller slices of the population and that's just kind of changed the game yeah so I suppose F what I'm getting from that is that like farac was was awesome in the '90s because of the the economic model that that was there for um medicines at that time that's
18:01
really slowly shifted and now we've got gone from like a I don't know if a a triangle to an inverted triangle is like the right approach but you know one drug can can be applied to many people versus one drug can be applied to only handful of people and and sponsors need to be able to recoup some of recoup some of their development and Manufacturing cost otherwise why would they do it yeah so it has
18:22
to be more expensive the problem therein is that the evaluation model for hasn't really changed over time to become to um you mentioned it's kind of like geared around cost minimization yeah and if everything's very expensive yeah might be too expensive for farx pallet yeah look I mean that that's I guess that's been kind of an ongoing challenge I suppose they they um remain very focused on on on Cost Containment and that kind of that that that budget piece is is still a very
18:50
important aspect of of what they do and they and they are doing it they still do a very good job at that I think the the the challenge that has been kind of recognized over time is that with the introduction of these sort of higher cost therapies it's been harder and harder to get funding for for a lot of those medicines right we just don't I guess we don't have the the the PHX kind of budget over time hasn't kind of grown commensurately with its responsibilities that
19:17
it's taken on and so it's it's um its ability to to pay it sort of purchasing power has kind of declined a little bit over time and so that's meant that fewer of those kind of high cost sort of targeted therapies have been able to get to Market and New Zeal to to be funded and really the way that that's been a bit of a it's been a bit of a slow kind of snowball I suppose over time really because pharmac really they have a we talked about they have a fixed budget and the the
19:46
ways that they get money really is either through new money from from government sort of granting them a larger budget or through generating savings out of their current their existing portfolio and they can do that by tendering for the existing portfolio of medicines that they have the generics and that that's been successful at sort of continuously driving you know a few to tens of millions of dollars of savings every year the other way is to is to wait for um medicines
20:16
that Innovative medicines to lose their their patent to lose their their exclusivity period and at that point other suppliers can start to manufacture those medicines right and then all of a sudden you've got competition and so that really pushes prices down because all of all of a sudden multiple players can deliver the medicines at a very much lower cost they don't have to worry about the all the recouping any development they're just coming in and they're supplying
20:39
right and so that's like your generics generics is yeah exactly that's exactly what it is and so that is the kind of like the third big way in which in which um farac Can can free up money within their existing budget and what's happened is over time that the the kind of the cupboard has kind of become a bit bare in terms of those inov of medicines because we've had a more difficult time
21:00
introducing new medicines into the into the New Zealand Market you know we've sort of relatively speaking compared to oecp is we've probably funded maybe you know less than half of what we might have seen new Med new kind of entities out of Australia or maybe you know less again if you looked at the UK or Canada so we because we've sort of underinvested a little bit in in that kind
21:23
of innovative medicine space we're not seeing that kind of those sort of patent Cliffs that that kind of occur that then create more space for the next round of innovation and so it's been a it's kind of a a bit of a um vicious cycle I suppose in some ways of um underinvestment leading to less money available to invest in the next is the next thing yeah and um I mean I suppose if you're part of the
21:47
argument with these Market access applications you're comparing it to standard of care and if we're behind the eightball and standard of carewise in each each generation becomes more difficult to present that argument because we don't have that previous generation of s of care absolutely and that works in in sort of two key ways really it's a it makes the comparison a lot more difficult um there's a lot more uncertainty because you because you don't have those direct
22:09
studies you don't know exactly the magnitude of benefit that your new intervention can have over over a standard of care that might be you know two or three iterations behind what your clinical study has has adopted right and so that's that's a challenge and um agencies um HT agencies are are sort of very much um adverse risk adverse to uncertainty they they sort of see uncertainty as as a sort of a difficult concept and they would use uncertainty as a as a way of sort
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of justifying for a lower price for the medicine or or perhaps trying to control sharing some of that risk in terms of in in financial ways like caps to to Total expenditure or things like that and so that's a that's a real issue and that that makes the just the evaluation piece more difficult and um so you play that out over like successive generations and it just becomes more and more more
23:06
complex or could you say at a certain point it might be impossible to compare unless you do like a bridging study yeah yeah yeah which that's an added cost in itself that's added time in itself and um all the while you have you know potentially scores of patients that are missing out on the uh modern available medicines that cousins over in Australia or the UK or the us would have access
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to absolutely promptly yeah absolutely and and I guess just the economics of it is is also changes quite a lot you know if you've got a a very cheap standard of care that it makes the the the level of benefit that even though it's sort of a little bit uncertain the level of benefit over over a older standard of care might be higher but the jump in cost is often very high as well and so you it's a it's a more difficult um comparison to make just from a sort of a health economic
23:56
perspective because often the the magnitude of of benefit change is not quite at the level of the kind of the cost impact sometimes that that that medicine will will deliver so it makes it a lot the system step sort of making small steps is a lot kind of makes it a lot easier for new innovation to arrive than if you're trying to make sort of consistent Quantum leaps in in in Access yeah yeah um what I find really interesting about that is that um if you applying a Quantum
24:26
Leap in technology at the healthare level that in itself is is very difficult as well I mean you can't expect to go from you know lepur to like a cellen gene therapy for whatever you know overnight that's going to be yeah uh quite quite a challenge so there's other far further reaching ASP um uh complications as well with having this like delayed approach Quantum Leap Reliance on um having access to new medicines yeah I mean it's not an easy um what would be
24:56
the the answer then I mean I mean is it we the the the strategy needs to change from a cost minimization approach or a cost control approach to more what are the actual outcomes that patients are receiving and what is the utility or the I mean cost benefit analysis that kind of applies everything th it's like everything but the kitchen sink into the calculation in terms of benefits or outcomes right I mean there needs to be a change surely yeah I mean I think I mean that's that's
25:24
a really that's a really interesting question I think and it probably it comes back a little bit to probably asking ourselves like what what do we want out of our health system and particularly our um our sort of drug purchasing agencies or our health technology purchasing agencies what's important to us because I think um at the you know we talked about it when when Farm was set up the focus was was to to make sure that we were getting good opportunity for good investment
25:52
we were paying sort of a commensurate amount for the for the purchasing power of our country and that was they did they've done an extremely good a good job at that and I I want to want to recognize as well that the the HTA system that we have in New Zealand is is is very robust it's a very good system it's it's it there are some issues with I think some of the aspects of how we operate it in
26:17
terms of its transparency and its um its ability to probably evaluate objectively I think the the challenge of the pharmac holding both the the kind of the evaluator and and budget holding kind of caps makes makes for some difficulty sometimes but I think overall it's a it's it's a good system for evaluating medicines I think where we run into often problems is is that the the model as a fixed
26:43
budget basically means that pharmac have to rank their investments from Best Value to to less good value and they just work their way down the list until they run out of money and then that's not to me that's not a particularly uh efficient way of allocating funds to a to a health investment because it might be that there are other medicines on that list of Investments that are also very
27:07
good value for money relative to other potential investments in health and because pharmac only have a certain amount of money to spend they don't they can't get to those Investments because theyve run out of funds before they get there and so I think one of the big changes that I I we sort of see is that there's a there's an allocative inefficiency happening by with with the use of siloed budgets within our within our health system and so there's I guess there's a couple of
27:34
ways that you could think about how you address that issue and one of them would be to try and bring the um the evaluation process of of of our medicines and Health Technologies in into line with other evaluation processes we see with other parts of government in order to make sure that we have kind of a a even comparison on what is a good investment and then by doing that you can make better allocative decisions you can you can sort of trade off well you know this medicine has
28:09
so many kind of quality just life years gained per dollar spend this um intervention over here in in infrastructure say like this road or this this safety measure on this particular stretch of highway will also deliver this many life years per dollar spent and So you you're able to say well actually I think that the money should be better spent over here or even just within Health you know this this more this investment into this particular infrastructure or this
28:37
Clinic that we set up in this particular city has um a a magnitude of benefit of value the because it is a little bit of a zero sum game I mean it doesn't have to be but at the moment in the current environment you know money spent somewhere is probably money taken from somewhere else and so you the idea being that you just need to be be better at being able to make investment trade-offs across the whole Health portfolio and I think the way that we kind of operate
29:07
things at the moment is not the most efficient way of doing things um there are ways in which I think that pharmac's methodology could be kind of brought into line with with those um other parts of government and that's probably considering the the broader value or the the broader benefits that medicines have on society more generally I think we we do take a very narrow view of what those
29:34
benefits are we look to the the health benefits to the patient and we we we sort of look at the costs to the health system as a as a kind of a narrow view but you know for a lot of conditions for medicines that are um very effective or even just you know just moderately effective I suppose there are there are there are benefits Beyond just that to the the health of the patient you know that if they if they're able to return to work earlier there are productivity gains for
30:02
society if they're able to um just take care of themselves I suppose a bit better than that has benefits for their immediate Faro or or family around them you know often the carers and so there are benefits beyond the patient that we don't count in our in our evaluation that that have real kind of societal benefit and in other parts of um cost benefit and all done in other parts of government those those societal costs and benefits are taken into account and so we're kind
30:30
of disadvantaging Health investment a little bit by not counting those things because often that is benefit we're leaving on the on the table we're leaving it off to the side yeah um and by doing that that I think that would probably make Health investment look more attractive relative to other areas and and perhaps would would sort of justify greater investment in that space yeah yeah I mean
30:54
we do that in our own personal lives right we go like how much value am I getting out of this I think abis and I talked about a coffee like the most rudimentary um you know comparison but you do it in your personal life so why wouldn't you do it at the the most fundamentally important Health level which is throw in Everything But the Kitchen sync at the evaluation to make sure you're making
31:15
that right decision yeah at least I mean you want to understand what the what the major drivers are and what the major benefits are and I think you know there's there's doing this within a within a kind of a cost benefit analysis is is one of the tools that you should use I think it's it's worth pointing out that cost um cost utility cost benefit analysis they're their decision- making tools right they're not they're not providing you the answer they're providing you information
31:41
that still requires someone to make a difficult decision there's still going to be trade-offs and so what what we aim to do is to to provide the most holistic and most kind of accurate picture of what those benefits are and then you can decide where you ultimately put your money and so one of the focuses I guess one of the the common kind of I guess worries about adopting a societal perspective particularly adopting productivity as a measure within analysis is that it biases
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towards productive areas of society so that might be working age people or um you know or biases against people like children or elderly or or people who are unable to work and so what it I guess what you try to do is you you make sure that those costs are counted and that you have a clear idea of what that looks like but then CBA or or that kind of analysis is not the only piece of information that you would use to to make that decision ultimately you would look to because
32:43
it may be that you know we we we hold Equity of outcomes just as important as as um quantity or or overall kind of total outcomes that deliver right so we want to make sure that not only we getting good value for money but those outcomes are being delivered or distributed within a group or population of people that we want to see um benefit the most and so that kind of um efficiency versus um Equity argument is an important one and and yeah and cost benefit analysis particularly
33:17
of any type really doesn't directly answer that question and so you can you overlay these other kind of value judgments or preferences on top of all of that and that kind of gives you a kind of a framework to try and make better decisions yeah yeah it's really interesting point because we kind of think of everything being like sterile numbers calculations but as you literally just said but
33:39
you're overlaying your own values your own desires for your country or your Society over that and that might change their that's a different lens through it's like the lens through which you're looking at those numbers the numbers don't tell all the story but they tell a lot of the story and they could guide you to make maybe rank your decision- making yeah but then you apply those addition additional values over the top absolutely and you know we have a framework Farm
34:03
has a framework thats the consideration that look at broader impacts than just cost Effectiveness and I think what we what you what the difficulty is with that with that kind of framework is that it's not it's not always um clear how those different aspects are applied to different applications and so I guess you want to kind of see a sort of a formalized framework or sort a common framework that that applies those things in a in a consistent manner um and then it just just
34:31
I guess just being kind of open and transparent about how we're making decisions I think is very important it's kind of one of the I guess one of the core tenants of of any kind of good public policy practice right that that we should be able to understand how decisions are made and critique those decisions and say whether they are meeting like you say the preferences of of of the public
34:52
because ultimately this is it's it's it's public money it's it's taxpayer money so you want to see everybody has a bit of a kind of a stake in the in the game in a way that you want to see that the money is spent in the most appropriate or yeah consistent way with our values yeah so that kind of speaks to the strategy side of things maybe like you know how how decision making can be done
35:14
in a more modern framework that throws throws in all of those additional benefits and outcomes into the calculation but I'm sure there is also like a budgetary need um increase budgetary increase need as well I mean these these um these modern medicines are not cheap and I think I saw a figure that we're lowest than the oecd on medicine spend which is quite remarkable you alluded to that the
35:36
value for money that we do get out of that low spend is is remarkable but I mean you keep doing that over successive I think it comes it comes back to the question of like what do we what do we want what do we as a society what do we want our health system to be able to deliver and do we do we want better access to Innovative medicines and does that reasonably justify a greater level of investment in this area and I think you know that the process is set up to to try and assess
36:03
the level of the value of investment in this area and I think by making some of these other process changes you get a better sense of how medicines compare to other Investments and that's important I think it's probably reasonable to ask if we're spending enough in this space in order to deliver the kind of expectations of a of a sort of a um Advanced kind of economies Health System right and I think you're right we we um on a kind of a per capita basis or as a percentage of
36:32
our health spend our our spend on medicines is very low compared to our kind of oecp I think we spend you know two or three cents Sorry probably three or four cents on the dollar of our have our health spend on on medicines which is is quite a low proportion uh comparatively speaking and you you know we do get good health outcomes for that spin but I guess the question is should that is
36:54
that um the the ambition or the the the the kind of the kind of consistent with how we would like our our kind of Health System to to um to Value those kind of Investments or do is that kind of consistent really yeah um I mean I I would like to think that we'd move on from like a 90 style framework for decision- making and you know evaluating things um in in the 2020s yeah so yeah um yeah I mean I think that's right and I think you know with the recently far there there was a
37:27
there was a review of their of their operations and I think it went into a lot of detail on on and their processes and things like that and a lot of good good kind of feedback came out of that you know that the that there there should be a bit of a a more focus on on on transparency and then they better kind of more of a focus on on some of the obligations around T and and and the equity side of things I think that those are those are very important what was left out of that
37:54
review and it was probably one of the kind of key things was is farx budget sufficient to deliver the outcomes that they're being asked to deliver um which was which is kind of disappointing right because I think that's kind of the core question is is are they being they're doing the best with the hand that they're being dealt but is that is that ambitious enough or is that is that what we
38:20
want or would we want them to have a bit more money to to invest and and perhaps deliver some of these Better Health comes for new zealanders because it does feel like if you look um around countries that we would kind of commonly compare ourselves to Australia and the UK and Canada that we we are falling behind a little bit when it comes to medicine's access and you see there was an really great report um from the cancer control agency from Taho Taho and and they they
38:48
basically just highlighted a list of medicines in in in cancer so not even old cancer but just like sort of solid tumors where um between what what was funded and available in Australia and what was not in New Zealand and and these treatments were were sort of standard of international standard of care in in you know a dozen different cancer types and that that just weren't available to new zealanders here and I guess that's that just feels like that's a um a bit of a unfortunate
39:18
circumstance right like we we don't it shouldn't have to be that way I think if if you were um you know a patient who had just been diagnosed with one of these cancers you look at that and You' sort of sort of wonder why it was that Australia or Canada or the UK had found the reason to fund and that that New Zealand had decided not to and and so and partly that you know there are there
39:39
are economic realities to that we are a smaller country we don't have the we don't have the money that a larger Nation does to invest in these sorts of things but at the same time I guess you'd it's not always about just the total cost of therapy it's about it's about what coming back to that same sort of thing what is a good investment are these are these medicines good value for money and if they are then I think we'd like to see more of them made available to to patients
40:07
inuse people in useand yeah yeah absolutely sorry Hender I think your microphone's on I can hear the clicking Tri um anyway we can cut that out um all good so um maybe to drive drive that point home like if you've got a drug that prevents like hospitalization countless times throughout say say it provides a functional cure I think like there's a spin OFA span is that spin Bea maybe one oh yeah spinal mopy there we go yeah um you know incredibly expensive medicine like I think
40:40
it's like a million bucks or pup or something um you know but that would be a more or less a functional cure for a patient that does receive it um that would keep them out of hospital that would keep them in school that would keep them that would enable them to be employed yeah paying taxes so when you have like this big big lens of all the different benefits um it kind of makes that say it's a million a bit more palatable because you kind of amortizing the cost over over
41:06
that time span and adding in all the additional benefits that you wouldn't otherwise had if you just looked at $1 million on its own yeah yeah um so that's kind of kind of what you're alluding to plus values plus like societal implications yeah other obligations that we have Equity that kind of thing exactly exactly and I think those those are that's what the the process of the economic
41:28
evaluation kind of steps through right it's about not just the the cost of the intervention and and um the the the drug acquisition costs I suppose but all of those Downstream costs and benefits that you are going to acrw and there is a there's a kind of a key kind of affordability question around that as well you know that we often counter when you talk about selling gene therapy where it
41:49
perhaps might just be a oneoff one off very high cost at the very beginning but then you're if if if it does play out that way and you're kind of cured of whatever that Affliction or disease is then you've got a lifetime of benefit then that you can you you sort of like discount back to present day and and that's how you kind of justify or argue for these these kind of higher sticker prices but that you also have to balance that with is that affordable like can
42:15
we pay millions and millions of dollars today for all of this benefit Downstream and so that there needs to be a balance you need to kind of overlay both of those pieces together but I mean you're you're absolutely right and I think one of the the difficulties coming back again to the way that we structure our our our health spand and and the kind of the silid nature of budgets is that that can get in the way of of properly recognizing savings across different as parts
42:41
of our health system right and so if pharmac is responsible for managing pharmaceutical spending and and budget um but a medicine may not deliver kind of much in the way of extra Health outcomes to patients but might save a lot of capacity say within a within a other part of the house system say say it's a a different delivery method you go from an infusion to a to a pill and so all of
43:06
a sudden patients don't need to go to a infusion clinic and sit in a chair for six hours they can take a tablet at home and so there might not be any benefit directly to that patient but there's a huge benefit to the system but those costs aren't recognized by pharmac themselves they that might ACR to to Fator or to a different place the health budget right so there's a there needs to be and we
43:31
we try and we try and do this as well as possible you you count those costs and you try and um you that's outside of their remit so they're not recognized well yeah it it does and and even if even even if it even if they do find they they they do consider those costs and they they try and account for that that the fixed nature of the budget means that all of those those costs are shifted out of another part of the house system onto PHX budget which means that they have less
43:57
money to invest in something else and so there's there's it makes it hard to spread I suppose the the the benefits or the cost savings across a system where you've got very siloed buckets of money and so I guess one of the changes that you could kind of argue for I suppose is is a to try to free up that that allocation efficiency is to remove those silos and sort of have a central um purchaser or payer and keep pharmac as the as the evaluator with the expertise and all of the the
44:34
system that they the things that they do very very well keep them doing that and that's fantastic and then make recommendations to a central payer for instance and this is a lot of countries this is how their HDA systems work so Australia the UK and Canada I think all operate systems where they have an independent evaluator who makes decisions and assesses whether the investment is a good
44:54
investment or not make recommendations to Ministry of Health or Department of Health or someone else and then that Ministry of Health has remit across the whole of the health sector and so they can decide well yes that is good value for money we are going to invest money in that because it has savings to this other thing over here that I'm also responsible for and so that to me is value
45:15
our system makes that trade-off more difficult and I think that's one of the kind of key kind of challenges yeah so it's almost as though the the scope of what pharmac are looking at is a little bit too narrow for today's purposes when you know it's not just about a single medicine it's about like all the other interactions that a potential patient might have with the Healthcare System those costs are recognized currently outside of of pharmx remit so they're not built into the
45:38
analyses if we had the analysis at a higher level incorporating all of those costs and benefits and again looking at the values on top of that um it would be a lot more um fair is that a fair to say yeah well I guess it just I mean they are counted we do count them and so they they're presented as part of the economic evaluation and they are they are considered I suppose it's just when it when
46:01
it comes to actually investing in things it just creates a barrier because it's it's money that they are going to have to allocate within their budget for a benefit of another part of yeah and so that that just there are challenges to that and I suppose it just means that where their budget is fixed and not and not growing they can recognize that spend in their budget but it would mean that
46:24
something else is going to have to miss out and so that the savings that are over here aren't then reallocated into farx budget in order for them to kind of it to really truly be recognized as cost neutral and so they can then so it's like double counting the costs and undercounting the benefits because it's not part of their oh man It's Tricky well Matt this has been really interesting thank
46:47
you so much for sharing your expertise yeah um if people want to find out a bit more about Market access maybe get in touch um if they're interested in you know the this wider story but also the blending of Economics business and and science you have a chat where can they go oh look I mean there's there's great Societies in new Z I think one of the the the Fantastic things about a a small country is that the how uh accessible everybody is and the small network of of people
47:16
that you can join societies like espor or or um some of the health economic networks around and and that will give you a bit of a flavor for the the the industry in New Zealand you know reaching out to to people like myself directly through you know like I social media channels and things like that is another way to go um but yeah a brilliant thing about New Zealand is how open and accessible
47:39
generally people are and willing to to share their knowledge and their expertise and so I think just start reaching just yeah just reach out to people you know cold don't be afraid to cold email or kind of reach out and just ask questions and more often than not people are very very open to that awesome yeah there you go folks open invite go hard thanks Matt really appreciate thanks [Music] [Applause] [Music] joh
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