Survey to assess current methods used globally in health technology assessment and health care reimbursement

	ISPOR HTA IN REIMBURSEMENT WORKING GROUP
	Survey to assess current methods used globally in health technology assessment and health care reimbursement

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Section A: Organization information

1. Organization Name:
2. Country:

3. Is the organization a reimbursement agency or HTA body?

	Reimbursement only
	HTA only
	Both
	Other (Please state in the text field provided)

4. How would you classify this organization?

	National/Central/Federal Government
	Local/Provincial/State Government
	Professional (e.g. medical society)
	Pharmaceutical/Medical Industry
	Academic/Not for profit
	Hospital
	Private insurer/managed care
	Other (Please state in the text field provided)

5. What is the purpose of HTA in your organization? (check all that apply)

	Support of coverage or reimbursement decisions
	Support of pricing decisions
	Support of clinical guidance
	Other (Please state in the text field provided)

6. Who funds the health technology assessment?

	Entirely government funded
	Mainly government funded with some private contribution
	Entirely privately funded
	Mainly privately funded with some government contribution
	Other (Not defined above, or a combination of the above (please state in the text field))

7. Who initiates the health technology assessment? (check all that apply)

	HTA agency
	Government
	Insurance company
	Health care provider
	Professional (e.g. Medical society)
	Pharmaceutical/Medical Industry
	Patient
	Other (Please state in the text field provided)

8. Where is the assessment work performed? (check all that apply)

	Entirely in-house HTA staff
	Combined HTA entity staff & outsourced professionals
	Entirely outsourced
	Academia
	Other (Please state in the text field provided)

9. What types of technologies are assessed? (check all that apply)Definitions of terms

Drugs - any chemical, biological substance or biotechnology that may be applied to, ingested by, or injected in order to prevent, treat or diagnose a disease or other medical condition.

Device -any physical item, excluding drugs, used in medical care

Medical or surgical procedure -a practice of a health care provider that generally involves a combination of special skills or abilities with drugs or devices or both.

Support system -a system that provides the environment for and otherwise facilitates the provision of health care, but is not the focal technology in a medical regimen, surgical procedure or other form of health care.

Organizational or administrative system - a system used in management and administration to ensure that health care is delivered effectively.

	Drugs Pharmaceuticals Biologicals Vaccines
	Medical devices
	Other technologies Medical or surgical procedure Organization or administrative system Support System Other

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