What is the Special High Cost Treatment Pool?
The Special High Cost Treatment Pool is money set aside by the Ministry of Health for one-off treatments not otherwise funded by the public health system. District Health Board specialists apply to the Ministry of Health on a patient's behalf.
What is the purpose of the Special High Cost Treatment Pool?
The purpose of the special high cost treatment pool is to:
" ensure fair access throughout the country to special high cost treatments
" manage the financial risk for certain highly specialised procedures that pose a financial risk to District Health Boards due to their unknown or fluctuating costs
" promote the use of cost-effective procedures in the public health care system
" provide a mechanism for procedures requiring further evaluation or costing analysis before being devolved to District Health Board contracts
What types of treatments do special high cost treatments include?
Medical treatment overseas.
Examples are:
" Twin twin transfusion syndrome (www.tttsfoundation.org.
" Diffuse Multiple Pulmonary Arteriovenous Malformations (http://www.chestnet.org/education/online/pccu/vol13).
" Deep Brain Stimulation.
" Congenital Adrenal Hyperplasia (www.tdh.state.tx.us/newborn/hand_cah.htm).
" Diode Laser Treatment for melanoma of the eye (www.emory.edu/EYE_CENTER/retina.2_press_frame.htm).
" Epilepsy surgery :neuro.med.cornell.edu/NYH-CMC/res19a.html.
" Embolisation of the Arteriovenous malformations of the Brain: neurosurgery.mgh.harvard.edu/neurovascular.
" simultaneous pancreas and kidney transplants. See Transplantation Society of Australia and New Zealand Inc (www.racp.edu.au/tsanz).
" treatment not currently available within the public health system, for example, gender reassignment surgery, see The Harry Benjamin International Gender Dysphoria Association website (www.hbigda.org) a professional organisation devoted to the understanding and treatment of gender identity disorders.
" complex cases, for example, separating Siamese twins.
What are the most common high cost treatments and what do they cost?
The cases all vary and so do their costs.
Overseas treatments tend to be the most expensive but even these vary a lot from $1000 to $200,000.
Another group of patients whose treatment costs are very high are haemophilia patients who require tolerisation. With this condition, some people with haemophilia develop antibodies that block the action of the clotting factors they normally use. They therefore require a particular product to reduce antibodies. This treatment is an investment, as we know it will make a huge difference to the patient's quality of life and it is also cost effective as it reduces hospitalisations and other problems. The one-off treatment can cost between $400,000 and $1.7 million per patient.
See Haemophilia Foundation of New Zealand,(www.haemophilia.org.nz)
Who can apply for special high cost treatments?
Applications are accepted from District Health Board specialists with supporting documentation and recommendations for treatment. The clinicians make the case for why a particular patient would benefit from the treatment. Before the application is made there has usually been a lot of clinical discussion between the referring clinicians and those who will provide the treatment.
How many people are accepted for special high cost treatments each year?
About four out of every five applications were accepted in 2001, with around 40 patients receiving treatment.
Some applications were declined because the funding for treatment was already available elsewhere in the public health system. The number of patients applying for high cost treatment is demand driven but there do not appear to be growing numbers of applications each year.
How are applications considered?
Access to the Special High Cost Treatment Pool is determined by the clinical advisor responsible for administering the pool who needs to follow the Ministry's statutory objectives and functions.
The eligibility criteria listed below are used as a guide for assessing applications. Each case is also considered for exceptional circumstances beyond the criteria. The Ministry of Health has also set up advisory groups of clinicians, who can advise on appropriate treatment decisions and best practice guidelines for cases that require extra clinical decision-making.
What are the eligibility criteria for applications for medical treatments overseas? 1. The appropriate treatment must not be available in New Zealand. 2. The treatment has proven efficacy through appropriate clinical trials, and preferably has also been established as effective when applied in regular practice. 3. The chosen treatment is cost-effective, which means that:
a) the expected long term savings to the health care system outweigh the initial costs of the treatment; and/or
b) the dollar costs for the expected benefit are acceptable when evaluated against other Ministry of Health priorities 4. Failure to receive the treatment could result in serious irreversible deterioration in the patient's condition or an inability to recover lost function, or significant impairment to normal development of a child; or
Failure to receive the treatment could deny an adult with a lifelong disability access to treatment, which would lead to a marked improvement in their quality of life. 5. Treatment would lead to reasonable prospects of survival and to an improved quality of life after treatment. 6. The treatment is well established and not an experimental form of treatment. 7. In cases where the above eligibility criteria are clearly satisfied approval will be granted directly by the Clinical Advisor.
What are the eligibility criteria for Simultaneous Pancreas and Kidney Transplants?
These cases are prioritised by clinicians from the DHBs.
What are the eligibility criteria for Special High Cost Treatments Currently Available Only Outside Public Hospitals? 1. The treatment must not be currently available from any public hospital in New Zealand or under any existing contractual arrangement. 2. The treatment has proven efficacy through appropriate clinical trials, and preferably has also been established as effective when applied in regular practice. 3. The treatment is well-established and is not an experimental form of treatment. 4. Failure to receive the treatment would result in serious irreversible deterioration in the patient's condition or an inability to recover lost function, or significant impairment to normal development of a child; or 5. Failure to receive the treatment could deny an adult with a lifelong disability access to treatment, which would lead to a marked improvement in their quality of life. 6. The chosen treatment is cost-effective, that is:
a) the expected long term savings to the health care system outweigh the initial costs of the treatment; and/or
b) the dollar costs per unit of benefit are acceptable when evaluated against other Ministry of Health priorities. 7. Treatment would lead to reasonable prospects of survival and to an improved quality of life after treatment.
What are the eligibility criteria for complex cases?
Complex cases are cases that are rare, high-cost, clinically complex and risky. Separating Siamese twins is an example of a complex case.
How much money is in the high cost fund each year?
The budget in 2001/2002 was $6.5 million.
