I. Locus of Assessment: Make or Buy?

Health care decision makers can “make or buy” HTAs. The nature of an assessment problem will affect the determination of the most appropriate organization to conduct it. A comprehensive HTA addressing multiple attributes of a technology can be very resource intensive, requiring considerable and diverse expertise, data sources, and other resources.

Some ministries of health and national health services, major insurance companies, health plans, and integrated health systems have their own internal HTA programs. For example, in a large hospital or health plan, this might include a core staff and a multidisciplinary HTA committee representing major clinical departments, nursing, pharmacy, allied health, biomedical engineering. This committee might interact with other committees such as pharmacy and therapeutics (P&T), strategic planning, and capital planning committees (Kaden 2002).

Other organizations rely on HTA reports acquired from organizations that have devoted functions or otherwise specialize in HTA. As noted above, AHRQ commissions evidence reports, HTAs, and other reports from its EPC, most of which are affiliated with academic medical centers. In the UK, NICE commissions one internal center and four external centers (the National Clinical Guideline Centre, National Collaborating Centre for Cancer, National Collaborating Centre for Women’s and Children’s Health, and National Collaborating Centre for Mental Health) to produce its clinical guidelines. NICE also commissions designated academic centers to develop assessments/evidence reports in support of its various types of technology appraisals and guidance.

Other US-based vendors of HTA include, e.g., Blue Cross and Blue Shield Association Center for Clinical Effectiveness (CCE) (formerly the Technology Evaluation Center), Cochrane Collaboration, ECRI Institute, Hayes Inc., Institute for Clinical and Economic Review (ICER), Center for Medical Technology Policy (CMTP), Institute for Clinical Systems Improvement (ICSI), and the Oregon Drug Effectiveness Review Project (DERP). Depending upon the producing HTA organization, these reports may be available at no cost, for members only, on a subscription basis, or for a specific price per report.

Determining the responsibility for sponsoring or conducting an assessment depends on the nature of the problem, financial resources available, expertise of available personnel, time constraints, and other factors. For any assessment, an organization must determine to what extent it will conduct the HTA itself or commission it from other sources. Some organizations commission selected components of an HTA, such as evidence retrieval and synthesis, and perform the other steps in-house.

One of the advantages of requesting or commissioning an outside group to conduct HTAs is to gain an independent, outside view in instances where a requesting agency might have a perceived conflict of interest. Thus, a major health care payer might seek an HTA from an outside group to inform its coverage decision about a costly new technology in order to diminish perceptions of a potential bias regarding its willingness to pay for the use of the technology.

Factors that influence the "make or buy" decision include the following (Goodman, Snider 1996).

• Is an existing assessment available? If an existing assessment is available, does it address the specific assessment problem of interest, including the technology or intervention, patient population, and impacts of interest? Does it have a compatible perspective? Is the assessment still current? Is the methodology used sufficiently credible? Is the report worth its price?
• If an existing assessment needs to be updated or is not available, do people in the organization have the time and expertise to perform the required data collection and analyses? If a synthesis of existing information is needed, does the organization have database searching capabilities and staff to review and interpret the literature? If new data are needed, does the organization have the requisite resources and expertise?
• What methodology will be used? If, for example, a consensus development approach is involved, does that consensus need to incorporate and reflect the opinions of an organization's own clinicians? Will local clinicians accept the results and report recommendations if they do not participate in the assessment?