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Reconciliation of Economic Arguments and Clinical Practice

Reconciliation of Economic Arguments and Clinical Practice. Monday November 4, 2002 ISPOR, Rotterdam Jan Busschbach PhD, Department of Medical Psychology and Psychotherapy, Erasmus MC Psychotherapeutic Centrum ‘De Viersprong’ Busschbach@mpp.fgg.eur.nl

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Reconciliation of Economic Arguments and Clinical Practice

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  1. Reconciliation of Economic Arguments and Clinical Practice • Monday November 4, 2002 • ISPOR, Rotterdam • Jan Busschbach PhD, • Department of Medical Psychology and Psychotherapy, Erasmus MC • Psychotherapeutic Centrum ‘De Viersprong’ • Busschbach@mpp.fgg.eur.nl • Elly Stolk, Marten Poley, Werner Brouwer • institute for Medical Technology Assessment (iMTA), Erasmus University

  2. Medical Technology Assessment • A combination of arguments • Health economic • Juridical • Social • Ethical • What are these other arguments? • Are they important? • How can we use them?

  3. Ad hoc arguments • If 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

  4. 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 • Faire innings • Looking backwards • Total health • Viagra: when you get older, erectile dysfunction is not longer considered a disease • Alan Williams

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

  6. PTO elicits extreme values

  7. Psychometrics • Paul Kind • If we look at TTO and PTO... • we see that one of them is wrong • If we look at PTO alone... • We still see that one of them is wrong... PTO is not a quick fix

  8. Incorporated equity in model • Weight QALY by equity • Wagstaff 1991 • Equity-efficiency trade-off • Dunning’s Funnel • 1990 • Government declaration 2002 • Necessary care • Need • Equity elements • Efficacy • Cost effectiveness • Own account and responsibility

  9. Funnel suggest no interaction • The criteria are called sieve • Dutch: “zeven” • An intervention passes the sieve or it stays on top • “Only after the health care intervention has passed the sieve, the next criterion is applied.” • Stronks, 1995 • The suggestion is wrong • Dunning 2002 • The funnel is an interactive model • Necessary care (equity) interacts with (cost) effectiveness

  10. Several definition of equity But what if the severity of illness is a result of old age? • Severity of illness • How bad is it now? • Fair innings • How good has it been? • Necessary care • Is this a normal life? Discriminate the old? How do we define “a normal life”

  11. 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

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

  13. 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

  14. A shifting threshold

  15. Practice

  16. CE-ratio by equity

  17. 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 • We accept a high cost per QALY • Ad the price of a lower average level of health in the population • We reduce variance at the price of lower average health in the population

  18. Implication • Ethics can be measured • Makes health care policy more understandable • Reimbursement of lung transplantation • Bad cost effectiveness, high burden • No reimbursement of Viagra • Good cost effectiveness, low burden • Explains the existence of burden of disease studies

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