The paper by Schulenburg et al. published in this issue, is written at a time of significant change in the German health care system. The Institut für Qualität und Wirtschaftlichkeit im Gesundheitswesen (IQWiG) has been in existence for three years and its remit is now being extended to include economic assessments.

The purpose of the paper by Schulenburg et al. is to set out the current international standards for economic evaluation of health technologies and to discuss their relevance in the German setting. At this time it is important that Germany draws on experience, both good and bad, from those countries that have already implemented a requirement for economic evaluation of new health technologies. These include Australia, Canada, and several European countries, for example Finland, Norway, Sweden, the Netherlands, Belgium, Portugal, and the United Kingdom.

Experience from abroad can be considered under two headings: methodologies and processes. In considering methodologies, it is apparent that, although methodological guidelines in the various jurisdictions are fairly similar, there are also key differences.

The most contentious items are: (1) the perspective for the analysis (i.e., consideration of health care payers’ costs only, or all social costs); (2) the measure of health gain (e.g., the quality-adjusted life-year, or alternative); (3) the role of economic modelling; and (4) the characterisation of uncertainty. Currently, one of the most contentious issues in Germany is the role of economic modelling. In some jurisdictions, for example the UK, modelling is welcomed, because it enables the analyst to provide data on the most relevant health outcomes. In Germany, there is currently some hesitation over the use of these techniques, because they require additional assumptions to be made, in extrapolating beyond the data observed in randomised controlled trials, for example.

With respect to processes, different jurisdictions employ different approaches with respect to: (1) the selection of technologies for appraisal; (2) the use of independent assessors; (3) the involvement of stakeholders (e.g., manufacturers, professional groups and patient organisations); and (4) the transparency of the process. Although no national HTA programme is without its problems, the most widely accepted seem to be those that encourage broad stakeholder involvement and have a transparent process. As HTA develops in Germany, it will be important to ensure that these characteristics are embraced.

Also, experience shows that the assessment procedures employed must be rigorous and defensible. In some jurisdictions, for example the UK, this is achieved by commissioning external (academic) research groups to undertake a peer-review of technology appraisals conducted by industry or government. Attention must be paid to how this rigour might be achieved in Germany.

Finally, as HTA develops in Germany, it is to be hoped that the German experience can, in turn, be used to inform development of the field in other countries. In the long term it may be possible to achieve more harmonization of the methodologies and processes for HTA in European Union member states.