The true role of horizon scanning in Australia: Who it informs and why

To the Editor:

The article by O'Malley and Jordan (2009) contains fundamental errors and misunderstands the process it claims to describe (4).

The premise of the paper is that the Australian and New Zealand Horizon Scanning Network (ANZHSN) “was set up to scan the introduction of new and emerging medical technologies into the public sector, with consideration to the private sector.” However, the terms of reference of the policy body (HealthPACT) directing the ANZHSN's activities state that its role is to “provide a forum for monitoring, reviewing, and sharing information regarding health technology to inform service planning and policy development in the public sector” (1). HealthPACT is largely a jurisdictional committee, with representation from the Australian Government, each of its seven states and territories, the New Zealand Health Ministry and district health boards.

To fully appreciate the role of the ANZHSN, the Australian health care system must be understood. In Australia two forms of “public health funding” exist: federal, with the Australian Government—advised by the Medical Services Advisory Committee (MSAC)—funding the universal health insurance scheme, Medicare; and jurisdictional, with public hospitals funded by state and territory governments under a federal/state cost-sharing agreement. The private health sector provides private hospitals and dental care (5). At the federal level, new medical technologies and procedures assessed by MSAC and approved for public funding are assigned a Medicare Benefits Schedule (MBS) item number for use by general practitioners or private hospitals (3).

O'Malley and Jordan assert that “it should not be possible for a manufacturer/distributer of a NEMT to submit a successful application for a full HTA to MSAC that has not already been assessed by Horizon Scanning”. However, the role of the ANZHSN is to identify technologies of interest to both the state/territory and federal governments, and as such the majority of technologies assessed relate to the public hospital system and, therefore, do not require reimbursement through the MBS or an MSAC assessment. Some promising technologies identified through HS may be referred to MSAC for a full HTA, however, these technologies would be in the minority (2). MSAC, however, is not obliged to conduct a full HTA on these referred technologies. The majority of technologies identified through HS are directly reviewed by the relevant policy and decision makers at the jurisdictional level who have the responsibility for allowing access to the technology within their state/territory.

The ANZHSN process is also misrepresented by the statement that “all prioritizing summaries are carried out as a result of a recommendation of HealthPACT.” The HS process is conducted independently of HealthPACT. The evaluators identify technologies and apply prioritizing criteria, with those not satisfying these criteria being archived (3). Many technologies satisfy these criteria but have little or no information available and are, therefore, monitored by the evaluators. Those technologies that satisfy the criteria and have sufficient data are prioritized by the HealthPACT membership.

O'Malley and Jordan consider that HS Reports are stand alone documents, however, these reports are only commissioned once a prioritizing summary (PS) has been written. HealthPACT can make several recommendations regarding a PS: archive, monitor, progress to HS Report or refer to another agency, including MSAC. An HS Report is not a systematic review, unlike a MSAC HTA, but rather involves a restricted search on the technology, and provides more detail than the technology snapshot captured by a PS.

There were several errors in the data presented by O'Malley and Jordan which we would have liked to expand on in greater detail than is available in this forum. Briefly, however, Table 1 lists MSAC applications commenced since the inception of HS in Australia with no prior PS, with the clear implication that a PS should have been conducted. It would be unrealistic for an HS network, founded in November 2003, to assess these first ten mature technologies assessed by MSAC. A prioritizing criterion of the ANZHSN is that technologies must be likely to emerge in the Australasian health scene within 3-years (3)—at the point of MSAC assessment the technology has already received regulatory approval and is well established in the health system. Table 3 lists MSAC applications that had a PS completed beforehand. It should be noted that the MSAC process supports applications for MBS reimbursement, that are submitted independently by industry and the clinical community, regardless of whether an HS assessment has occurred.

O'Malley and Jordan refer to the “extreme example” of digital mammography being assessed by the ANZHSN and MSAC several times. The authors, however, have cited a PS followed by an HS report (2004) on mammographic computer aided detection (CAD) systems as supporting their contention, in addition to the one PS completed on digital mammography in 2005, which was referred to MSAC. An MSAC assessment was completed and public funding for the technology granted in 2008. CAD and digital mammography are distinct technologies: CAD involves processing film X-rays to produce a low resolution digital image, whereas digital mammography by-passes the use of film completely.

The ANZHSN has a valuable role in providing timely information to jurisdictional and federal policy makers. The fact that the ANZHSN has received ongoing funding from federal and jurisdictional governments since 2003 indicates that policy makers at the coal face of technology introduction and reimbursement, at all levels of the Australian health system, are finding this early alert system is a useful resource to enable the coordination and control of technology diffusion across the country.

CONFLICT OF INTEREST

All authors inform their institution has received a grant from the Commonwealth Government of Australia to conduct horizon scanning.