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Reconciliation of Economic Arguments and Clinical Practice

Explore the combination of health economic, juridical, social, and ethical arguments in healthcare decision-making and reimbursement policies. Understand the role of ad hoc arguments, equity concerns, and the intersection of cost-effectiveness and equity in healthcare models.

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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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