Budget impact analysis has quietly become one of the most consequential methods in market access. As health expenditure continues to outpace economic growth, health technology assessment (HTA) bodies in many jurisdictions now expect a budget impact analysis (BIA) alongside a cost-effectiveness analysis before a new technology is funded. Other payers, such as hospitals and local commissioners, also expect to see this type of analysis before they commit to funding a new treatment or intervention. Where cost-effectiveness asks whether a technology offers good value, a BIA asks a blunter question: can this budget holder afford to adopt it, and what will it do to their spending over the next few years?
Which raises an obvious follow-up. If budget impact analyses are shaping real funding decisions, how good are the ones actually being published? And how many achieve the methodological standards set by the ISPOR good practice guidelines?
Case study: budget impact analyses of orphan drugs
In 2021, Khadidja Abdallah, Isabelle Huys, Kathleen Claes and Steven Simoens at KU Leuven published a systematic review in Frontiers in Pharmacology that put the question to the test. They searched PubMed, Embase and the ISPOR conference abstracts, screening 1,960 records and including 90 studies that analysed the budget impact of orphan drugs: 69 examining individual drugs and 21 examining orphan drugs in combination.
Orphan drugs are a demanding test case, and a revealing one. Patient numbers are small, data are scarce and prices are high, so the penalty for methodological shortcuts is severe. If the field’s methods hold up anywhere, they need to hold up here.
Each study was assessed against the ISPOR good practice guidelines for budget impact analysis – the closest thing the discipline has to an agreed standard – across parameters including perspective, target population, data sources, time horizon, scope of costs, assumptions, sensitivity analysis, discounting and validation.
What most studies got right
The picture was not uniformly bleak. Most studies adopted a third-party payer perspective, as ISPOR recommends. Time horizons typically ran from one to five years, with budget impacts reported periodically rather than as a single aggregate figure. Discounting was rarely applied – correctly, since a BIA is meant to reflect the budget holder’s actual expected cash flows rather than a discounted present value.
Where the analyses fell short
The first major gap concerned the eligible population itself. ISPOR recommends modelling an open population, with patients flowing in as they are newly diagnosed and flowing out as they die, recover or discontinue treatment. Among the 69 individual-drug analyses, only 17 (25%) modelled the population dynamically. Thirty-seven (54%) treated it as static and a further 14 (20%) did not report on population dynamics at all. The reviewers acknowledge that a static population can be defensible where the eligible group is very tightly defined, but as a default it runs contrary to good practice.
The second gap concerned assumptions – specifically, where they cluster. The single most assumed input across the review was not cost: it was the size of the target population, assumed in 56 (81%) of studies, ahead of assumptions about the intervention or comparator (47 studies, or 68%) and far ahead of assumptions about costs (just 7 studies, or 10%). In other words, the number these models depend on most heavily is the number most often asserted rather than sourced.
Assumptions are not, in themselves, a flaw. Every analysis requires them, and orphan drug research is genuinely data-poor – the authors describe resorting to assumptions as “disadvantageous but inevitable”. The problem is what happened next, which in most cases was nothing. Thirty-seven (54%) studies reported no sensitivity analysis of any kind, and only one conducted a probabilistic sensitivity analysis. The input carrying the greatest uncertainty was, in the majority of published analyses, never tested.
Validation completed the pattern: 65 studies (94%) made no attempt to corroborate their results against stakeholder opinion, comparable analyses or any other external reference.
There were narrower findings too. Across the review as a whole, only around half of the analyses costed anything beyond the drugs themselves, leaving out administration, adverse events and other condition-related costs that can materially change a budget holder’s true exposure.
A fair reading
It would be easy to read all this as an indictment against the authors of these BIAs. But that would be wrong. Eighty-three per cent of the individual-drug analyses were conference abstracts, a format with little room to report sensitivity analyses even when they were performed. Rare disease data are scarce by definition, and the review found that full-text publications generally did better than abstracts.
The fair criticism is narrower and more useful: not that assumptions were made, but that they were so rarely justified and so rarely tested. That is a discipline problem – and disciplines can be taught.
What good practice looks like
The reviewers’ recommendations track the ISPOR guidelines closely. Model the population as it actually behaves, with influx and efflux over the time horizon. Cost more than the drug. Justify every material assumption and subject each one to sensitivity analysis, so the reader can see how much weight the conclusion places on it. Validate the results – against budget holders, against comparable analyses, or ideally both – and have inputs and formulas checked by a second modeller. And motivate methodological choices explicitly, so the analysis can be appraised rather than merely believed.
Underneath all of that sits one transferable principle. The inputs you are least certain about need to be the main focus of your sensitivity analysis.
Building budget impact models that meet the standard
These are precisely the skills HEOR Institute’s budget impact analysis course is designed to teach: a practical, hands-on course on how to design, build and present budget impact models for health technology assessments, business cases and value propositions, using Excel. Participants work through the full arc of a BIA – framing the analysis, estimating the eligible population, modelling the treatment mix, costing the comparison and testing the result – to the methodological standards required by national and ISPOR good practice guidelines.
The “Hello My Name Is…” campaign is a compassionate care campaign founded by the late Dr Kate Granger, a geriatrician and crusader for better patient care who launched a movement to remind healthcare staff of the importance of introducing themselves properly to patients. Thanks to her work a small, human-centred change is making meaningful improvements to patient experience.
But, in an ideal world, should Dr Granger’s campaign have ever been necessary? Introducing yourself properly is surely essential to becoming a trusted caregiver?
And wouldn’t patients be less anxious and more satisfied with their care if a standardised communication framework was universally adopted across all hospitals?
In fact, shouldn’t health payers, whether public or private, be helping to focus healthcare leader’s attention on patient experience by explicitly tying hospital reimbursement to patient satisfaction scores?
These are just a few of the questions we explore and answer in the Institute of Healthcare Leadership and Management’s patient experience and service excellence course – a course for anyone who wants to design and deliver more person-centred, compassionate and responsive care.
Pretty much everyone working in business or management has heard of the MBA degree. However, few healthcare leaders have the time, money or need for such a lengthy and expensive programme.
What is often more useful and relevant to a frontline healthcare leader is an accelerated programme that will give them the skills, knowledge and capabilities they need to overcome the most urgent and immediate challenges their health service faces.
That’s where so-called mini MBAs such as IHLM’s popular Healthcare MBA Essentials course really come into their own. They distil the most relevant and important content from a one or two year MBA programme into a course that can be studied in a fraction of that time. At IHLM we’ve designed our course to require just 40 hours of learning – that’s 4 hours a week over 10 weeks.
Other than length, what are the other big differences between a mini MBA and a full Master of Business Administration degree?
Qualification – You don’t get a degree at the end of a mini MBA but you do get a professional certificate that you can immediately showcase on your resumé.
Specialisation – Mini MBAs can be more useful than a full MBA because they enable you to focus on specific topics and how to apply them to the industry sector you work in.
Cost – Mini MBAs are inexpensive compared to MBA degrees. For a two-year MBA at a prestigious institution like Harvard you would pay almost $150,000 in tuition fees plus another $80,000 in living costs. Mini MBAs, by comparison, start at around $1,000 and can often be studied online.
Employment opportunities– A MBA degree is often required for senior positions in management, consulting and finance. But for frontline healthcare leaders, a mini MBA certificate will show your current or future employer that you’re serious about developing yourself and making a positive impact on the quality of care.
Entry requirements– The most prestigious MBA programmes have tough entry requirements that need excellent test scores, references and exam transcripts. Mini MBAs, on the other hand, are usually available to anyone with a desire to learn.
Availability and accessibility – Universities have just one or two start dates per year for MBA degrees whereas mini MBA courses have multiple start dates – often once a month.
In summary, mini MBAs are a great way to enjoy the same learning experience as a full MBA degree. That means the same chances to collaborate with others and the same opportunities to develop practical skills. For an aspiring healthcare leader or manager, IHLM’s Healthcare MBA Essentials course provides an immersive, interactive and supportive learning environment that will enable you to have a real impact on the performance of your healthcare service – all at a fraction of the cost and commitment of a full MBA degree.
Improving Productivity and Patient Flow
The global Covid-19 pandemic created enormous challenges for healthcare providers and left them facing an unprecedented backlog of people waiting for treatment. In the UK, for instance, there is a ‘visible backlog’ of more than 6 million people waiting for elective procedures and a growing ‘hidden backlog’ of patients who require care but have not yet looked for it. There has never been a more urgent need to maximise the capacity and productivity of our healthcare facilities and services, but how do we do this?
In IHLM’s upcoming Healthcare Operations and Patient Flow Management programme we’ll be taking an in-depth look at some of the many ways healthcare teams can transform productivity, while also improving the quality of their working lives. These solutions include:
seeing patients in turn and treating them in order – allowing a patient to jump the queue for non-clinical reasons means everyone else behind them waits longer
ensuring that capacity meets variation in patient demand by reducing staffing levels on some days and increasing it on other days
making sure every stage in the patient’s journey is planned for and scheduled so that everyone knows what to expect and when to expect it
reducing the time spent doing things that don’t add any value for patients – such as coming to hospital on different days for different tests
Delivered via IHLM’s online e-learning platform, through live interactive Zoom webinars and one-to-one coaching, our upcoming programme will help you become part of a global community learning how to transform patient flow together.
Celebrating International Nurses Day With Course Discounts
Today, we celebrate International Nurses Day on the anniversary of Florence Nightingale’s birth.
The theme of this year’s celebration is Nurses: A Voice to Leadwhich focuses on the need to protect, support and invest in the nursing profession to strengthen health systems around the world.
Nurses are, and have always been, at the frontline of care. They have worked bravely and tirelessly despite their extreme workloads during the COVID-19 pandemic. But too many nurses continue to be underpaid, undervalued and to work in unsafe environments.
As a special thank you gift from IHLM to both nurses and the entire global healthcare community we’re offering a 30% discount on all our upcoming courses. Simply enter the discount code IND30 when you register.
This discount reduces the price of a 10 week course from £895 to £626 and reduces the price of an 8 week course from £695 to £486.
Hurry though, because this sale is available for four days only and expires at midnight on Sunday 15 May.
Did you know that this week has been World Health Worker Week? Unfortunately, despite being networked with many thousands of healthcare staff across the world neither I, nor any of my colleagues here at IHLM, heard any mention of it. No one posted about it in our Linkedin feeds or mentioned it in the many emails that arrived in our inboxes this week. 😥
It is shame that this important event – organised by the Frontline Health Workers Coalition, the World Health Organisation and other partners – did not receive more publicity. As we were reminded during the global Covid-19 pandemic, the world’s 59 million healthcare workers are one of the most valuable resources our planet has. Their sacrifices must be better recognised, their voices must be better heard, their health and safety better protected, and their needs better met.
Another reason we, at IHLM, were sad not to be able to organise our own events over the last week was because this year’s theme – “Build the Health Workforce Back Better” – is one that is very strongly aligned with our own mission to help transform the competencies and capabilities of the healthcare workforce and, in so doing, support improved health outcomes.
We shall certainly make sure that, this time next year, we organise a number of activities to support this important week. But, for now, one small and immediate contribution we can make is to offer a 20% discount on all our upcoming online courses for registrations received over the next three days.
To claim 20% off an IHLM online programme simply register and make payment using the discount code WHWWeek2022 before midnight this Sunday.
– Benedict Stanberry
Fight The Sludge!
I’ve heard many words used to describe the things that cause unnecessary waits, delays and aggravations for both patients and caregivers.
The US Institute for Healthcare Improvement, for instance, encourages healthcare leaders to help their teams identify ‘the pebbles in their shoes’ – ie, the things that get in the way of doing what matters. Fans of Lean Thinking, on the other hand, will be very familiar with the term ‘muda’, the Japanese word for waste, which is defined as any human activity that absorbs resources but creates no value.
Now, however, we have a new word to help us identify healthcare improvement opportunities: ‘sludge’.
The word was first coined by author Cass Sunstein to describe situations in which systems are seemingly designed to impede people from doing what they need to do. He concedes that it’s okay to impose a little bit of sludge to make sure that those who are trying to get something actually have a right to that thing. So being triaged before being given a GP appointment or having to wait for your medical insurer to approve a consultation is probably acceptable as long as it’s done as quickly as possible. The problem, however, is that healthcare systems frequently create sludge that prevents people getting timely access to care or deters them from seeking it in the first place.
Fortunately, in an insightful recent Harvard Business Review article, three senior healthcare managers have described how they use ‘sludge audits’ to measurably improve patient care and increase employee engagement by eliminating or reducing anything that adds unnecessary time and cost to healthcare encounters.
So next time you’re casting around for ideas for an improvement project, maybe think about rolling up your sleeves and clearing out some sludge!
– Benedict Stanberry
IHLM Announces New Strategic Partnership with THE Institute
IHLM is delighted to announce a new collaboration with THE Institute: an international and independent non-profit organisation that provides education and other knowledge-transfer services to healthcare providers and systems.
The partnership with THE Institute will broaden access to IHLM’s courses and programmes, enabling us to reach an even larger audience of healthcare professionals and executives in Europe, the Middle East and Asia. It will also make our programmes available for the first time in the Benelux market of Belgium, the Netherlands and Luxembourg, as well as bringing opportunities to involve French- and Dutch-speaking experts in our growing faculty of instructors and coaches.
European healthcare faces many challenges – including a growing and ageing population, the increasing prevalence of chronic diseases and a shortage of skilled healthcare workers. But it also has an unprecedented opportunity to exploit the latest advances in digital technologies and design thinking to deliver better health outcomes and a more responsive patient experience. IHLM’s expanding portfolio of specialised programmes enable hospitals and health systems to overcome these challenges and exploit these opportunities by transforming the skills, knowledge and performance of their greatest asset: their people.
We are very excited to be working with THE Institute to make our online, blended and in-person programmes available to more healthcare leaders and managers than ever before and to developing new learning experiences that address their ever changing needs.
Among all the many skills, abilities and competencies needed to deliver great healthcare there’s probably none more important than effective teamworking.
Not only does our own lived experience of working in healthcare tell us this, but so too does the wealth of research that demonstrates a consistent link between teamwork and patient outcomes. This is why IHLM have made effective teamworking the subject of the first in a series of free books that we will be publishing over the coming months. Launched in Bangkok at the recent Hospital Management Asia conference and exhibition, Effective Teamworking in Healthcare shows you:
the characteristics of healthcare teams
why teams and teamworking matter in healthcare
the most common obstacles to effective teamworking
how to measure the effectiveness of a healthcare team, and
how to develop healthcare teams and improve teamworking.
Whether you want to reduce medical errors, improve staff engagement, use limited resources more effectively or simply enhance patients’ experiences of their care – developing teams and improving teamworking are absolutely essential. Follow this link to download your own copy and after you’ve read it, tell us what you think!
Improving the Patient Experience with Executive Walkrounds
For the last 10 to 15 years, walkarounds have been widely used in healthcare organisations to improve safety and there is evidence that they lead to a better safety culture and increased understanding of safety risks (Singer and Tucker, 2014).
However, there is also evidence that walkarounds only lead to such results when they are implemented authentically, and with the full commitment of higher management and senior physicians who are actually able to act upon and resolve problems. Half-hearted, insincere or ineffective walkarounds can backfire. I have personally seen situations where walkarounds became a form of surveillance and control, rather than enquiry and support. I have also seen situations where managers controlled or restricted conversations with patients and staff in order to avoid topics they didn’t want to discuss, or where higher mangers said they would address problems but, in the end, did not do so.
So, while there seems no reason why walkarounds cannot have a very positive impact on patient experience, they have to be designed, planned and implemented in the right way.
There are seven things to get right:
(1) Higher Management Support– You must have the full commitment and participation of higher management and the patient experience department must provide the necessary resources in terms of time, staff, budget etc.
(2) Tools – You must design and develop the orientation and training materials with which to prepare higher managers for walkarounds. These should include defining what patient experience is and the staff practices and behaviours on which it depends; the purpose of walkarounds; the aspects of the patient experience that they should be focusing on during a walkaround and guidelines for initiating conversations with patients, families and staff.
(3) Scheduling– You may need to schedule walkarounds many weeks or even months in advance in order to accommodate the schedules of higher managers, senior physicians, department/unit managers, patient experience specialists, and other walkaround participants. You will also need to decide where to conduct the sessions and may choose to pilot walkarounds in just one or two departments to begin with.
(4) Communicating – There needs to be a clear communication strategy for the walkaround programme so that all staff know about walkarounds in general and what their aim is. There also needs to be focused communication immediately before, during and after a visit with information leaflets for patients and families, as well as for staff.
(5) Visiting – The walkaround itself needs to begin with a proper briefing on the department/unit to be visited, including any existing areas of concern or previous complaints received. The team needs to agree on the aspects of the patient experience they will focus on and the questions they will ask. There must be an immediate debriefing, after the walkaround, to agree the issues that must be taken away for action, quick fixes that can be resolved straight away, actions that staff can take immediately if empowered to do so and feedback or praise that should be given where good practices have been identified.
(6) Supervising and Following-Up– You must set-up processes for collecting information during walkarounds, for sharing that information, for assigning action items to the right people and for making sure actions are done and that feedback is given to staff, patients and family members. A follow-up walkaround should be arranged to monitor progress.
(7) Measurement – You must set-up a measurement process to evaluate whether or not walkarounds are delivering the objectives you require. Metrics could include the number of walkaround visits performed, the number actions identified and completed, decreases in patient complaints and/or increases in compliments and satisfaction levels.
