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.

Only people who are New Zealand citizens or permanent residents may be considered for treatment funded under the Special High Cost Treatment Pool.

Applications are only accepted from District Health Board specialists with recommendations for treatment. Specialists provide supporting documentation and evidence for why a particular patient would benefit from the requested treatment.

Special high cost treatments includes medical treatment that is only available outside New Zealand, or treatment that is only currently available outside the public health system, for example, in private hospitals.

More information on the Special High Cost Treatment Pool is provided below.

Examples of medical treatments covered

Also covered are complex cases, for example, separating conjoined twins.

Costs for treatments

Overseas treatments tend to be the most expensive but even these vary, from $50,000 to $2.5 million.

Applying for special high cost treatments

District Health Board specialists apply to the Ministry of Health for funding on a patient's behalf.

Applications are only 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.

About 20 to 30 applications are approved each year.

Some reasons for applications being declined will be because the funding for treatment is already available elsewhere in the public health system; the treatment is still exploratory; it is not considered high cost. 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.

Considering applications

Access to the Special High Cost Treatment Pool is determined by the Senior Advisor responsible for administering the pool. They need to follow the Ministry of Health’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.

In cases where the eligibility criteria below are clearly satisfied, approval will be granted directly by the Senior Advisor.

The Ministry of Health has access to a number of clinicians with different health specialty backgrounds to support decision making, treatment decisions and best practice evidence for cases that require extra clinical input.

Eligibility criteria for applications for medical treatments overseas

  1. The 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:
    • the expected long-term savings to the health care system outweigh the initial costs of the treatment
    • the dollar costs for the expected benefit are acceptable when evaualted 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
  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. Treatment would lead to reasonable prospects of survival and to an improved quality of life.
  7. The treatment is well established and not an experimental form of treatment.

Eligibility criteria for special high cost treatments (generally available only outside public hospitals)

  1. The treatment generally must not be 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, which means that:
    • the expected long-term savings to the health care system outweigh the initial costs of the treatment
    • 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.

Eligibility criteria for complex cases

Complex cases are cases that are rare, high-cost, clinically complex and risky. Separating conjoined twins is an example of a complex case.

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