Managed Uptake of Medical Methods

• Abstract
• Purpose of health policy or idea
• Characteristics of this policy
• Political and economic background
• Purpose and process analysis
• Expected outcome
• References

Featured in half-yearly report: Health Policy Developments 11

Abstract

Managed Uptake of Medical Methods (MUMM) is a joint effort of Finnish specialised care providers (represented by the hospital districts) and Finohta. The main objective is to build a national system of early assessment of new technologies and joint recommendations on the uptake of these methods, based on rapid reviews. Clinicians are involved in producing the reviews, and hospital and municipal decision makers make final decisions on uptake based on these recommendations.

Purpose of health policy or idea

The purpose of the programme is to develop a national structure for managed uptake of medical methods in secondary care, hence the name MUMM. It is a programme, a joint effort of Finnish public sector specialized care (20 hospital districts) and the Finnish Office for Health Technology Assessment (Finohta) that is taken to make assessments of new medical methods which are considered to be taken into use in hospital districts in the near future. The MUMM reviews that are being produced are meant to provide essential material and evidence on methods for the hospital decision makers. MUMM is not set up specifically to contain costs, but to better manage uptake of new methods.

The Finnish healthcare system is extremely decentralized and the around 400 municipalities in the end decide the level of health care services (primary and secondary care) they provide for their inhabitants. Related to this there are currently marked differences between hospital districts on how and when they uptake new methodologies.

Finohta has been assessing technologies used in health care (others than pharmaceuticals) and promoting the use of evidence-based methods in health care from the year 1995 onwards. However, there has not been any explicit method to nationally co-ordinate the implementation of the assessments (except for the screenings). By the MUMM programme hospital districts are tried to be involved actively in the process of production and implementation of the assessments of the new technologies.

Main points

Main objectives

A permanent national level programme for uptake of new medical methods, which is capable of making joint recommendations on which the hospital directors can base their decisions. Objective of the programme is decreased geographical variation in clinical practice and improved equity.

Type of incentives

None that are to be used in conjunction specifically with this programme.

Groups affected

decision makers in specialised care, clinicians in specialised care, patients indirectly

Degree of Innovation	traditional		innovative
Degree of Controversy	consensual		highly controversial
Structural or Systemic Impact	marginal		fundamental
Public Visibility	very low		very high
Transferability	strongly system-dependent		system-neutral

The MUMM programme is about to bring a major change in the decision making culture in Finnish specialized care. The uptake of new medical methods will become more controlled and systematic, with much more emphasis on safety. Since practically all hospital districts providing public specialized care in Finland are involved, there is a chance of more centralized decision making.

There are similar initiatives in progress in other countries e.g. Sweden, Denmark and Spain. MUMM also clearly relates to the EuroScan activities, early awareness and assessment of emerging technologies.

Political and economic background

There has been irrational variation between hospital districts in the pacing of uptake of new medical methods. The economic background is the perceived continuing increase in the cost of health care and a desire to reign this increase. Consumerism provides a fruitful ground for ever increasing demands to use the latest technology, whether it is a true innovation or not.

Change based on an overall national health policy statement

The current Government Programme states that the evidence base of health care will be strengthened - see HPM 10/2007

Purpose and process analysis

Current Process Stages

	Idea	Pilot	Policy Paper	Legislation	Implementation	Evaluation	Change
Implemented in this survey?

Origins of health policy idea

Repeated discussions on methods to assess and appraise nationally new medical technologies and coordinate uptake of them have taken place within the group of hospital directors and medical directors, especially those of the university hospital, since the turn of the millennium. A lot of discussion has also taken place concerning evaluation of methods that are currently in use but may be obsolete. These directors took a joint decision in September 2005 to commence such an effort. The focus of the programme was set on new methods since methods that are already in use in everyday practice are more difficult to remove.

The overreaching policy of the Ministry of Social Welfare and Health is to improve the evidence base of the health care system, aiming to make sure that the methods used are as far as possible assessed to be efficacious, effective and safe. This principle is also stated in the Government Programme of the current Government (see HPM 10/2007).

Initiators of idea/main actors

• Government

• Providers: Hospital districts

• Scientific Community

Approach of idea

The approach of the idea is described as:
new:

Innovation or pilot project

Local level - Hospitals are setting up their local committees and decision making practices of taking up new technologies

Stakeholder positions

The decision to start this programme was made by the directors of hospital districts. So basically the key stakeholders have been involved in the programme from the outset.  It was considered appropriate to start within specialised care and then later (maybe and if appropriate and possible) move on to primary care. Of the 20 hospital districts, 18 were visited by the programme staff in the spring of 2006. A second round is currently underway, with the general idea of keeping these stakeholders involved and interested. Also the Ministry of Social Affairs and Health has been involved from the outset and is aware of the progress of the programme.

Frontline clinicians have been interested in the programme, with various attitudes from positive to very negative. The reason for negative attitudes is the question about clinical autonomy and the tradition of using whatever devices, diagnostics and drugs found useful. These clinicians seem to feel that they are themselves the best judges of what is and should be used in clinical practice.

The HTA specialists at Finohta back up the programme. Medical scientists vary in their position, some have misgivings about excessive bureaucracy.

Actors and positions

Government
Ministry of Social Affairs and Health	very supportive		strongly opposed
Providers
medical directors	very supportive		strongly opposed
clinical specialists (MDs)	very supportive		strongly opposed
Scientific Community
HTA specialists	very supportive		strongly opposed
Medical scientists	very supportive		strongly opposed

Influences in policy making and legislation

So far there are no effects on legislature.

Legislative outcome

n/a

Actors and influence

Government
Ministry of Social Affairs and Health	very strong		none
Providers
medical directors	very strong		none
clinical specialists (MDs)	very strong		none
Scientific Community
HTA specialists	very strong		none
Medical scientists	very strong		none

Positions and Influences at a glance

Adoption and implementation

The main actors in adoption and implementation are hospital districts which have been involved from the outset. The hospital districts jointly produce the MUMM reviews and make national recommendations on which then individual hospital districts can base their own local decision making. If hospital district managers are really committed they should be able to lead their clinicians to use this information as recommended nationally.

Structurally, the programme has been light, with one fulltime person at Finohta leading the network. The main forum for the network has been a biannual seminar, where representatives from the hospital districts have come together to discuss MUMM. In these seminars, the results of the MUMM reviews have been presented and discussed.

There is apprehension regarding building up too much bureaucracy into the programme. Despite this, it is now been agreed that a more robust structure is needed. At present, the hospitals have formally nominated their representatives to become members of a MUMM committee for three years, with one of the university hospitals' medical directors as committee chair. The committee will select a working group of 6 to 8 clinicians, which task it is to prepare the committee meetings (decisions on topics and the joint recommendations).

The MUMM reviews are made by groups consisting of 1-2 assessment experts and 1-3 clinical specialists depending on the topic. The production process will be sped up so as to be able to produce the reviews in about six months. The reviews will be published in the Finnish Medical Journal and on Finohta's website.

Implementation of the results of the reviews begins by having involved the leaders in specialised care to select the methods for assessment. Formulating joint recommendations based on the reviews is the next step, to be followed by local decision making and implementation in the hospitals. How this will actually work remains to be seen. The three year term of the first committee will prove crucial for the future of MUMM.

Monitoring and evaluation

An evaluation of the MUMM programme will probably be undertaken in 2010, when it has been running for a few years and has become mainstream and routine.

Review mechanisms

n/a

Expected outcome

In order for the MUMM programme to succeed, changes have to take place in the culture at two levels, the hospital and municipal level, as well as at the national level. In hospitals, more consideration and more careful evaluation before uptake of new methods need to be instigated. This will somewhat harness the clinical autonomy of physicians who in the past have been allowed to start using whatever new methods are available according to their own clinical judgement. Also hospital and clinic leaders will need to take more responsibility in decision making and become stronger clinical leaders.

At the national level, a new way to make recommendations in cooperation will need to be learned. Methods such as the Delphi procedure may have to be used. Greater equity may be expected if joint recommendations are implemented throughout the specialised care sector. At all levels a slowing of the uptake processes may be seen.

An undesired side effect may be that uptake of even safe and effective methods may be slowed down. It remains to be seen whether the private sector can be made to abide by the recommendations (so far private sector is not involved in the MUMM programme). Negative development would be if private hospitals would start to more explicitly compete on  taking up new medical methods 'first in the country' without considering MUMM reviews.

At present, the public sector is committed to the programme. The following three years will show whether or not this is a workable system, and what kind of changes need to be made.

Impact of this policy

Quality of Health Care Services	marginal		fundamental
Level of Equity	system less equitable		system more equitable
Cost Efficiency	very low		very high

The MUMM programme may have far reaching and significant effects in specialised care, especially on the decision making culture.

References

Sources of Information

Kaila, Minna. Managed uptake of medical methods. Impakti - Finohta newsletter 2/2007: 12-13. http://finohta.stakes.fi/NR/rdonlyres/2872CE40-7E60-400C-9CAD-FC1466378B11/0/impakti2007_2.pdf

Author/s and/or contributors to this survey

Kaila, Minna

Senior Medical Officer, Finnish Office for Health Technology Assessment (Finohta)

Suggested citation for this online article

Kaila, Minna. "Managed Uptake of Medical Methods". Health Policy Monitor, April 2008. Available at http://www.hpm.org/survey/fi/a11/2