The happiest health economist

By Megan Brodie 1 week ago | In Companies, People
  • 1 week ago

8 July 2024

“I am an optimist – I always have been. I love what I do and have a strong belief that health technology assessment (HTA) and health economics make a real contribution to society,” says James Ryan, Global Director of HTA Policy, HTA and Modelling Science at AstraZeneca Oncology – and arguably the world’s happiest health economist.

Ryan wholeheartedly believes he has the best job in the world and, given the way he lights up when talking about his job – and his reputation for finding the positives in every scenario – for him, it is true. But had this happy economist could well have taken a different path and was almost a jolly airline pilot instead.

“I discovered economics at around 16 when it was the only option available on the school timetable,” Ryan told MedNews. “After 10 minutes in my first economics class, I thought wow, this is for me. Supply and demand resonated in a heavenly way; it was rational and logical and I loved it.”

Ryan went on to get his undergraduate degree in economics and was considering joining British Airways and pursuing his love of flying when a scholarship offer to complete his Masters in Health Economics at the University of York won over – and he has never looked back.

“I genuinely love the job I do,” he says. “I love the idea that the whole world is a trade-off and that choices have to be made. That’s what health economics is all about. Where there’s a cost, there’s a benefit, but what trade-offs are you making?”

After finishing his Masters, Ryan stayed on at York as a researcher before moving into consulting, then into industry, first with Bayer then AstraZeneca.

“I joined AstraZeneca in 2011 because I liked the culture,” says Ryan. “Pascal [Soriot] joined as CEO shortly afterwards with a vision to refocus on the science and wow. Pascal brought a new energy to the company, while it was also on the cusp of a whole new wave of oncology medicines. Thirteen years on, I’m still here.”

As AstraZeneca’s oncology portfolio exploded, Ryan was tasked with leading the team responsible for delivering the payer evidence that ultimately enables equitable patient access. He started out designing clinical trials, the experience leaving Ryan with a strong appreciation for good trial design.

“You need to predict the future and understand the differing needs of payers in five to six years time,” he says. “There is an opportunity cost in delivering evidence through clinical trials and you can’t keep adding more and more on just to meet the needs of a range of payers.

“For example, comparators will always differ across countries, but you can’t have a trial with 10 different comparators. You have to choose one or two. Trials can also only go so far, so there will be an evidence gap. What additional evidence are you going to collect?”

Conducting global trials and adapting the evidence for local decision-makers is one of the greatest challenges of Ryan’s role, and another reason why he loves his job. He sees translating data into evidence to help inform better decision-making as his core purpose, yet admits this is not without its frustrations.

He says payers can be more concerned about avoiding funding a medicine that provides no benefit than funding a medicine that does, using HTA methodology as a reason not to invest rather than to inform better decision-making or to find a path forward.

“In most cases, new medicines deliver a benefit over time and with longer term data, you will see an overall survival benefit, but if you’re not going to reimburse it until you’ve got all the evidence, patients that could have benefited during that two or three year delay missed out, and that’s not right either,” he says.

“There’s an opportunity cost to that just as there is an opportunity cost to making the wrong decision. This is where a payment model can help account for the financial risk due to remaining clinical uncertainty whilst providing coverage as further evidence is developed.”

Ryan says personalised medicines are offering high response rates in areas where other drugs previously failed and the field of HTA is quickly moving beyond randomised control trials and mature outcomes, and payers are struggling to keep up. He sympathises with them, saying they have a difficult task given patients are pushing for access, but notes some markets are coping better than others.

Australia’s is currently reviewing its HTA policy and methods for the first time in 30 years, one option put forward being that new medicines claiming equal benefit to existing medicines should offer a discount to secure reimbursed market access.

Ryan says if payers do not want to discuss the benefit a new therapy may offer, this negates the years and heavy investment in developing evidence to demonstrate a benefit and questions why developers should bother at all, again calling on payers to have an honest conversation with developers about their product and the benefits they provide.

“Are we seen as just a data provider, or are we seen as a partner in trying to solve some of the healthcare system challenges that lie ahead? he says. “If we are just doing HTA for cost containment, why are we doing it at all?

“I’ve always got hope but using HTA as a shield is a waste of patients’ time and a waste of evidence. Let’s be honest. If you’re not interested in the benefit, let’s just leave it out. It’s expensive for developers, its expensive for patients and it’s expensive for clinicians, plus the committees that evaluate it, but I don’t think that is right.”

As countries like Australia grapple with HTA as a tool to deliver faster access and sustainable health systems, Ryan points to markets like Germany that separate discussions on clinical benefit from pricing negotiations while delivering faster access and system sustainability, demonstrating what is possible.

He says rational discussions around benefits, uncertainty and willingness to pay are crucial, but to do this, trust is required.

“Trust has to go both ways,” he says. “Trials are done in a global setting and the comparator a market may want is not the one used in most clinical sites, so let’s have a discussion around where the evidence gaps are and how we can address those. Let’s have a meaningful exchange so you can get to a better decision. Trust only comes from engaging and talking.

“My experience in Australia, for example, is that they allow indirect comparators, but don’t allow you to show an additional benefit over time to the comparator. This means if you don’t have the comparator they want, you are more likely than not to end up with a decision of no added benefit.

“The other challenge in Australia is having different routes for medicines, vaccines and co-dependent tests. How does it all work together?”

Ryan says while he loves the concept of a Quality Adjusted Life Year (QALY) as much as any other avid health economist, he recognises it does not capture the patient’s view of their own health state, which means it has limitations that need to be taken into account.

“It comes back to what we are trying to achieve and, as HTA practitioners, we should be trying to get the best information to inform decision-making,” he says. “HTA should not be the decision-making tool; it’s not a black and white consideration. That’s why patient input and clinician input is important – it can’t just be a cost per QALY argument.”

While Australia waits for the outcome of its HTA Review, Ryan is also hopeful the country may offer a more flexible submissions system than its current 17-week PBAC submission cycle, once again pointing to the German system.

“In Germany, as soon as you get marketing authorisation you can put in your HTA submission and patients get access,” he says. “You get your IQWIG assessment and final benefit rating within six months, after which you are in pricing negotiations. Within the year, you’re done.

“When you look at wait indicators for Australia compared to Japan, Germany and the UK, it can take two to three times longer to get final reimbursement in Australia. The process is quite formulaic in a sense. If you’ve missed deadlines or timings to submit, you’re waiting and waiting for the next opportunity, and that leads to more potential delays.”

While challenges with HTA are part of a global debate where the problems are complex and the answers not easily derived, Ryan is often referred to by his peers as a beacon of hope; a ‘glass half full’ man who can always find an upside. Perhaps it is his love of health economics, or maybe just who he is, a jolly Brit with a ‘joie de vivre’ that would have seen him happy whatever he chose to do.

Regardless, the complex field of HTA is better off for having James Ryan as a key player, as are the thousands of cancer patients who have benefited from access to AstraZeneca’s medicines through the evidence Ryan and his team have delivered, the trust they have built up, and the many conversations they have had. And as for Ryan, the future is indeed very bright.

“There’s always hope!” he says happily, and indeed James, there always is.

©MedNews 2024

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