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QALY, Burden of Disease and Budget Impact

This study examines the relevance and role of other arguments, such as juridical and ethical considerations, in health economic decision-making. It explores how these arguments are used when traditional economic evaluation fails and discusses their impact on reimbursement decisions.

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QALY, Burden of Disease and Budget Impact

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  1. QALY, Burden of Disease andBudget Impact • Jan J.V. Busschbach, Ph.D. • Erasmus MC, Rotterdam, The Netherlands • J.vanbusschbach@erasmusmc.nl • www.Busschbach.nl • Issue Panels – Session IITuesday, May 22, 2007 2:00 PM – 3:00 PM

  2. 3600 Citations in PubMed

  3. Health economics is not the only argument • Reimbursement decisions are a combination of arguments • Health economic • Juridical • Ethical • What are these other arguments? • Not clear in Juridical and ethics • Are other arguments important? • How can we use them?

  4. What are the ‘other’ arguments? • Used when economics evaluation ‘fails’ • Reimbursement of lung transplantation • No reimbursement of Viagra • First, debate about the validity of the health economics • lung transplantation: not all cost of screening / waiting list should be included • Viagra: preferences for sex (erectile functioning) can not be measured • Secondly, ad hoc arguments are used • lung transplantation: it is unethical to let someone die • Viagra: erectile dysfunction in old men is not a disease

  5. Ad hoc argument repressed equity concerns • Severity of illness • Looking forwards • Prospective health • lung transplantation: it is unethical to let someone die • Rule of rescue • Necessity of care • Eric Nord • Fair innings • Looking backwards • Total health • Viagra: when you get older, erectile dysfunction is not longer considered a disease in old men: you had your fair share • Alan Williams

  6. Person trade-off • Incorporates equity concerns in QALY • Nord / Richardson / Murray 100 persons additionally 1 healthy year ?? persons 1 year free from disease Q

  7. PTO differs from TTO Susan Robinson, iHEA 2001Also: Report Health Services Management Centre, Birmingham

  8. Psychometrics • “If we look at TTO and PTO… • …we see that one of them is wrong” • Paul Kind, iHEA 2001 Susan Robinson, iHEA 2001

  9. Psychometrics • “And if we look at PTO alone… • …we still see that one of them is wrong…” • Paul Kind, iHEA 2001

  10. Incorporated equity in model • Weight QALY by equity • Wagstaff 1991 • The higher the burden of disease • The more money we are willing to spend • The higher the QALY threshold • A floating threshold…. • Might be the reason we could not find it…

  11. A floating threshold

  12. Drawback • The more differentiation of the threshold… • The lower the population health • If we spend all our money in curing the worst of patients… • All others die sooner… • Equity-efficiency trade-off • Wagstaff 1991

  13. Several definition of burden (equity) • Fair innings • How good has it been? • Severity of illness • How bad is it now? Discriminate the old? But what if the severity of illness is a result of old age?

  14. Prop. Short Fall = 60% Prop. Short Fall = 50% QoL  Prop. Short Fall = 50% QALY gain QALY lost Now t  Prop. Short Fall = 25% Proportional short fall • Compares loss in QALY with expected QALY • The higher the proportion • The higher the need for equity compensation

  15. Intermediate position • Fair innings • Looking backwards • Total health • Severity of illness • Looking forwards • Prospective health • Proportionalshort fall • Intermediate Health patient A Proportional short fall Fair innings patient A Now Prospective health patient A Birth t 

  16. What can we do with it? • Better understand health policy • Why are some cost effective treatments not reimbursed • Why are some not cost effective treatment reimbursed • Cost effectiveness interact with equity • Is there indeed a shifting threshold? • Tested in policy practice

  17. CE-ratio by equity

  18. Burden as criteria Pronk & Bonsel, Eur J Health Econom 2004, 5: 274-277

  19. Dutch Council for Public Health and Health Care (RvZ, 2006) € 80.000

  20. Alternative interpretation:Budget impact….

  21. Budget impact • The Third Man • Next to cost effectiveness • Next to burden (equity) • Are we more willing to pay for: • Low incidences? • Are high incidences linked to low burden? • Opposition from economists • Abandoned efficiency as primary criterion • Like burden of disease • But might be relevant for policy…. • For good reasons

  22. Conclusions • Efficiency / Equity trade-off • The more severe the health state • The more we are willing to contribute • The more money we are willing the spend • Budget impact • High incident / prevalence are suspected • Possible link with burden

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