2.2 Economic evaluation, decision-modelling in health care, solidarity and distributional cost effectiveness Flashcards
limitations of all methods for utility values in QALY
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.
limitation of cost-utility values in QALY: analogue scale
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.
limitation of cost-utility values in QALY: time trade off
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).
limitation of cost-utility values in QALY: standard gamble
there are cognitive difficulties with appraisal and processing probabilities. Confounded with risk preferences.
er zijn cognitieve problemen met beoordelings- en verwerkingskansen. Verward met risicovoorkeuren.
limitation of cost-utility values in QALY: EQ-5D
not very specific in describing the health condition.
methodological critiques of cost-utility analysis
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
cost-utility analysis and welfare theory
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.
criticized the maximization of health approach: Musgrave
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.
criticized the maximization of health approach: Daniels
healthcare is of special moral importance, because it protects the range of opportunities that individuals have.
criticized the maximization of health approach: Sen
health contributes to a person’s capability to choose the life he/she has reason to value
main points why QALY’s are unethical
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
equity
a situation which we perceive as ‘just’ or ‘fair’.
horizontal equity
equal treatment for people who are equal in relevant respects (such as in terms of their needs or their characteristics)
vertical equity
more treatment for those who need it more (‘fair inequalities’)
horizontal and vertical equity and inequalities
whereas horizontal equity requires reducing unfair inequalities, vertical equity implies having fair inequalities.
causes of inequalities in health: three broad categories
- genetics
- social / physical environment
- lifestyle
causes inequality in health: genetics
women have a higher life expectancy than men
causes inequality in health: social / physical environment
level of education: higher level has a higher life expectancy.
causes inequality in health: lifestyle
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.
theories of justice and equity
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?
3 theories of distributive justice
utilitarianism as health maximization / egalitarianism / maximin (Rawls)
utilitarianism as health maximization
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.
key points utilitarianism as health maximization
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’
egalitarianism as theory of distributive justice
equality (in outcomes) is the central concept in egalitarianism
egalitarianism in terms of health outcomes holds that
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
maximin as distributive justice
neither a fully utilitarian nor an egalitarian basic structure of society
permits inequalities if it makes those in the least advantaged position better-off
difference principle (maximin)
inequalities are permissible only if they benefit the least well-off
two dimensions in equity of health
prospective / retrospective and health gained from care / health gained ‘free’
prosprective and retrospective
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.
health gained from care / health gained ‘free’
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.
four criteria basic insurance packages in the netherlands
necessity
effectiveness
cost-effectiveness
feasibility
necessity
is an important health problem involved?
effectiveness
does a treatment exist that can solve this problem?
cost-effectiveness
are the treatment’s effects reasonably in proportion with the costs?
feasibility
are the costs of treatment beyond the reach of the patient, but within the reach of society?
disease severity and equity
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.
ex-post
the policy with regard to who should receive treatment
ex-ante
the policy with regards to who should pay to enable treatment
income solidarity
people on higher incomes contribute more to healthcare than people on lower incomes
risk solidarity
you pay a health premium irrespective of your health status
