2.2 Economic evaluation, decision-modelling in health care, solidarity and distributional cost effectiveness

Question 1

limitations of all methods for utility values in QALY

Answer 1

utility valuation not identical across the population (region; patient vs. general population vs. physician).

There is a lack of utility independence: valuation of health state might depend on health state that arises before or after it.

Question 2

limitation of cost-utility values in QALY: analogue scale

Answer 2

more ordinal than cardinal: from 0.2 to 0.1 is not the same as from 0.6 to 0.5. Also, respondents do often not use the end of the scales.

Question 3

limitation of cost-utility values in QALY: time trade off

Answer 3

there is a constant proportional trade-off’-assumption (i.e. trading 2 years of 5 remaining years in total, is assumed to be similar to trading 20 years of 50 remaining years in total).

Question 4

limitation of cost-utility values in QALY: standard gamble

Answer 4

there are cognitive difficulties with appraisal and processing probabilities. Confounded with risk preferences.

er zijn cognitieve problemen met beoordelings- en verwerkingskansen. Verward met risicovoorkeuren.

Question 5

limitation of cost-utility values in QALY: EQ-5D

Answer 5

not very specific in describing the health condition.

Question 6

methodological critiques of cost-utility analysis

Answer 6

no clear definition of costs

too much variation in measurement techniques of
QALY’s

comparisons of studies from different years / regions can lead to wrong conclusions

validity / reliability concerns with utility measurement

discrimination against new / innovative treatments

insufficient sensity to small and clinically meaningful changes in health status

failure to acknowledge non-health related benefits

Question 7

cost-utility analysis and welfare theory

Answer 7

cost-utility analysis (CUA) is grounded in welfare theory, which relies heavily on the notion of individual rationality and the idea that we can arrive at the social good via individual preferences.

Question 8

criticized the maximization of health approach: Musgrave

Answer 8

certain goods are merit goods. These are goods we should want because they are good (positive externalities / long term benefits) rather than because we can or are willing to pay for them.

Question 9

criticized the maximization of health approach: Daniels

Answer 9

healthcare is of special moral importance, because it protects the range of opportunities that individuals have.

Question 10

criticized the maximization of health approach: Sen

Answer 10

health contributes to a person’s capability to choose the life he/she has reason to value

Question 11

main points why QALY’s are unethical

Answer 11

unethical to value one individual’s life over another’s

invites setting ‘arbitrary’ budget constraints on healthcare. leads to economic considerations leading.

using QALY’s in decision-making is too utilitarian, cicumstances are not taken into account

Question 12

equity

Answer 12

a situation which we perceive as ‘just’ or ‘fair’.

Question 13

horizontal equity

Answer 13

equal treatment for people who are equal in relevant respects (such as in terms of their needs or their characteristics)

Question 14

vertical equity

Answer 14

more treatment for those who need it more (‘fair inequalities’)

Question 15

horizontal and vertical equity and inequalities

Answer 15

whereas horizontal equity requires reducing unfair inequalities, vertical equity implies having fair inequalities.

Question 16

causes of inequalities in health: three broad categories

Answer 16

1. genetics
2. social / physical environment
3. lifestyle

Question 17

causes inequality in health: genetics

Answer 17

women have a higher life expectancy than men

Question 18

causes inequality in health: social / physical environment

Answer 18

level of education: higher level has a higher life expectancy.

Question 19

causes inequality in health: lifestyle

Answer 19

men and women with two or more of the behavioural risk factors (smoking, physical inactivity, obesity and alcohol consumption), could expect to live on average up to 12 fewer years than those with no risk factors.

Question 20

theories of justice and equity

Answer 20

theories of distributive justice can help to distinguish between different beliefs of what equity encompasses.

in virtually all accounts, equity implies some form of equality.

yet, the theories of distributive justice have different standpoints with regards to when deviation from equality are justified –> maximum health gains / reduce inequalities / prioritise those who are the worst off?

Question 21

3 theories of distributive justice

Answer 21

utilitarianism as health maximization / egalitarianism / maximin (Rawls)

Question 22

utilitarianism as health maximization

Answer 22

classical utilitarianism prescribes that we should take the actions that maximize happiness or well-being for all affected individuals, regardless of who wins or loses.

standard cost-effectiveness analysis (cost-utility and cost-benefit analysis) has strong links to this theory of justice.

Question 23

key points utilitarianism as health maximization

Answer 23

we should take the actions that maximize aggregate health outcomes

individual differences in preference for health are disregarded

health gains are weighed on a universal scale, regardless of the patient’s personal or social characteristics: ‘A QALY is a QALY is a QALY’

Question 24

egalitarianism as theory of distributive justice

Answer 24

equality (in outcomes) is the central concept in egalitarianism

Question 25

egalitarianism in terms of health outcomes holds that

Answer 25

we should aim “creating possibilities for individuals to become as much as possible equal to others” in terms of health (Leget & Hoedemakers, 2007).

not the individual but the objective measure of health matters.

patients with the greatest disease burden should receive the greatest attention

Question 26

maximin as distributive justice

Answer 26

neither a fully utilitarian nor an egalitarian basic structure of society

permits inequalities if it makes those in the least advantaged position better-off

Question 27

difference principle (maximin)

Answer 27

inequalities are permissible only if they benefit the least well-off

Question 28

two dimensions in equity of health

Answer 28

prospective / retrospective and health gained from care / health gained ‘free’

Question 29

prosprective and retrospective

Answer 29

should we only care about the years that are still to come (prospective) or do we also take the years that have already passed (retrospective) into consideration.

Question 30

health gained from care / health gained ‘free’

Answer 30

should we only take into consideration how many years are gained from treatment, or should we also take into account how many years a person would have lived without treatment.

Question 31

four criteria basic insurance packages in the netherlands

Answer 31

necessity

effectiveness

cost-effectiveness

feasibility

Question 32

necessity

Answer 32

is an important health problem involved?

Question 33

effectiveness

Answer 33

does a treatment exist that can solve this problem?

Question 34

cost-effectiveness

Answer 34

are the treatment’s effects reasonably in proportion with the costs?

Question 35

feasibility

Answer 35

are the costs of treatment beyond the reach of the patient, but within the reach of society?

Question 36

disease severity and equity

Answer 36

proportional shortfall bases the burden of disease on the fraction of QALYs that people lose relative to their remaining life expectancy, and not on the absolute number of QALYs lost or gained.

Question 37

ex-post

Answer 37

the policy with regard to who should receive treatment

Question 38

ex-ante

Answer 38

the policy with regards to who should pay to enable treatment

Question 39

income solidarity

Answer 39

people on higher incomes contribute more to healthcare than people on lower incomes

Question 40

risk solidarity

Answer 40

you pay a health premium irrespective of your health status