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

6. 6 PTO elicits extreme values

7. 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. 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. 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. 10 Several definition of equity Severity of illness –How bad is it now? Fair innings –How good has it been? Necessary care –Is this a normal life? But what if the severity of illness is a result of old age? Discriminate the old? How do we define “a normal life”

11. 11 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

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

13. 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. 14 A shifting threshold

15. 15 Practice

16. 16 CE-ratio by equity

17. 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. 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