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

2. 2 3600 Citations in PubMed

3. 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. 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. 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. 6 Person trade-off  Incorporates equity concerns in QALY  Nord / Richardson / Murray ?? persons 1 year free from disease Q 100 persons additionally 1 healthy year

7. 7 PTO differs from TTO Susan Robinson, iHEA 2001 Also: 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. 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. 11 A floating threshold

12. 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. 13 Several definition of burden (equity)  Fair innings  How good has it been?  Severity of illness  How bad is it now? But what if the severity of illness is a result of old age? Discriminate the old?

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

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

16. 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. 17 CE-ratio by equity

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

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

20. 20 Alternative interpretation: Budget impact….

21. 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. 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