QALY,%20Burden%20of%20Disease%20and%20Budget%20Impact

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QALY, Burden of Disease andBudget Impact

• Jan J.V. Busschbach, Ph.D.
• Erasmus MC, Rotterdam, The Netherlands
• J.vanbusschbach_at_erasmusmc.nl
• www.Busschbach.nl
• Issue Panels Session IITuesday, May 22, 2007
  200 PM 300 PM

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3600 Citations in PubMed
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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?

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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

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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

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Person trade-off

• Incorporates equity concerns in QALY
• Nord / Richardson / Murray

?? persons 1 year free from disease Q
100 persons additionally 1 healthy year
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PTO differs from TTO
Susan Robinson, iHEA 2001Also Report Health
Services Management Centre, Birmingham
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Psychometrics

• If we look at TTO and PTO
• we see that one of them is wrong
• Paul Kind, iHEA 2001

Susan Robinson, iHEA 2001
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Psychometrics

• And if we look at PTO alone
• we still see that one of them is wrong
• Paul Kind, iHEA 2001

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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

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A floating threshold
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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

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Several definition of burden (equity)
Discriminate the old?

• 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?
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Proportional short fall

• Compares loss in QALY with expected QALY
• The higher the proportion
• The higher the need for equity compensation

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Intermediate position

• Fair innings
• Looking backwards
• Total health
• Severity of illness
• Looking forwards
• Prospective health
• Proportionalshort fall
• Intermediate

Health patient A
Proportional short fall
Fair innings patient A
Now
Prospective health patient A
Birth
t ?
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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

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CE-ratio by equity
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Burden as criteria
Pronk Bonsel, Eur J Health Econom 2004, 5
274-277
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Dutch Council for Public Health and Health Care
(RvZ, 2006)
80.000
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Alternative interpretationBudget impact.
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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

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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