Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College Street, 4th Floor, Toronto, ON, M5T 3M6, Canada.
Department of Health Management, Evaluation and Policy, University of Montreal, Institute of Public Health Research of University of Montreal (IRSPUM), CP 6128, succ. Centre-ville Montreal, QC H3C 3J7, Canada.
Soc Sci Med. 2020 Nov;265:113528. doi: 10.1016/j.socscimed.2020.113528. Epub 2020 Nov 17.
The challenge of novel and high cost health technologies has encouraged the growth of regulatory agencies such as Health Technology Assessment (HTA) organizations and Group Procurement Organizations (GPO). Yet the existence of several agencies in the same polycentric regulatory regime raises questions about whether and how their work can be coordinated. Drawing on a case study of GPOs and HTA agencies across four provinces in Canada, involving document review and key informant interviews (n = 44) conducted between 2013 and 2016, we explore the separate evolution of these agencies, emerging connections between them for non-drug technologies, and the organizational processes and evaluative judgments that underpin coordination efforts. HTA agencies and GPOs developed separately; connections emerged recently in three provinces and suggest four modes of coordination. One mode aligns most closely with that recommended by health economists and HTA practitioners, whereby HTA precedes procurement, with coverage decisions informing technology acquisition. The second mode is a version of the first, where procurement refers cases to HTA for coverage or technology management support; unlike the first, it recognizes procurement's evaluative strengths. Yet both the first and second modes focus on exceptional cases and will be infrequent. The third mode is more systemic, reflecting a generalized complementary of purpose as public agencies. HTA could support GPOs in contested technology acquisition efforts through timely and responsive input, while procurement could expand HTA's impact and inform HTA's growing interest in responsible innovation and environmental sustainability. The final mode is non-coordination, reflecting the potential for agencies to occupy quite distinct regulatory niches within the same regime. We conclude that consistency and convergence around a single model of resource allocation is not inevitable; nor is it necessary for coordinated effort. Thus, where differences in regulatory practice and epistemology persist, mutual accommodation and shared learning may prove most productive.
新出现的高成本医疗技术带来了挑战，这促使诸如卫生技术评估（HTA）组织和团体采购组织（GPO）等监管机构得以发展。然而，在同一个多中心监管体制下存在多个机构，这引发了一些问题，即它们的工作是否以及如何能够得到协调。本研究通过对加拿大四个省的 GPO 和 HTA 机构的案例研究，利用 2013 年至 2016 年期间进行的文件审查和关键知情者访谈（n=44），探讨了这些机构的各自发展、它们之间在非药物技术方面的新兴联系，以及支撑协调努力的组织流程和评估判断。HTA 机构和 GPO 是分别发展起来的；在三个省份最近出现了联系，并提出了四种协调模式。一种模式与卫生经济学家和 HTA 从业者推荐的模式最为接近，即 HTA 先于采购进行，覆盖范围决策为技术获取提供信息。第二种模式是第一种模式的一种版本，其中采购将案例提交给 HTA 以获得覆盖范围或技术管理支持；与第一种模式不同，它承认了采购的评估优势。然而，这两种模式都侧重于特殊情况，且发生的频率较低。第三种模式更加系统，反映了公共机构作为一个整体的目的互补性。HTA 可以通过及时和响应性的投入来支持 GPO 在有争议的技术获取工作中，而采购可以扩大 HTA 的影响力，并为 HTA 日益关注负责任的创新和环境可持续性提供信息。最后一种模式是非协调，反映了机构在同一体制内占据相当不同的监管利基的可能性。我们的结论是，围绕单一资源分配模式保持一致性和趋同并非不可避免；协调努力也不是必要的。因此，在监管实践和认识论存在差异的情况下，相互适应和共同学习可能会更具成效。
