Michael Drummond, Professor of Health Economics, Centre for Health Economics, University of York
In a recent paper published in Behavioural Public Policy, Voorhoeve (2017) discusses an interesting take on the notion that health gains that are assessed to be equal in terms of quality-adjusted life-years (QALYs) are not viewed as being equal by members of the general public. Specifically, in several surveys respondents would prioritise large gains for a few individuals over small gains for a large number, sometimes infinite number, of other individuals.
Voorhoeve points to a number of shortcomings in the existing surveys with which I concur. In fact a recent systematic review by Shah (2017) suggests that the literature is quite confused over whether individuals would place a higher weight on health gains to people suffering from serious conditions, or near end of life. Framing effects are likely to be the main source of the heterogeneity in study results. There are particular problems with asking individuals about ‘saving lives’. Most ‘life saving’ treatments do not save lives, they reduce the probability that the patient will be dead in (say) 5 years. Indeed, the health gains from life-extending treatments are often be quite small (Drummond et al, 2014). However, whether an appreciation of this by respondents in surveys would affect their preferences is unclear. Also, in real life budget constraints exist that may impact on the choices that respondents say they would like to make. At the end of the day, health care priorities should take account of both the relative benefits and relative costs of the various possible treatment choices.
Nevertheless, I agree with Voorhoeve that there is an issue here that deserves more investigation, not least because decision-makers in several jurisdictions are struggling with the trade-offs between rarer and more serious conditions, and more common, less serious, ones. Voorhoeve mentions the policy in Norway, where the Committee for Priority Setting in the Health Sector proposes paying up to 3 times more for a QALY gained by someone facing a large health burden than for a QALY gained by someone facing a small health burden (Ottersen et al, 2016). To this we could add the adjustment to the cost per QALY threshold for serious conditions in Sweden (Persson, 2012), NICE’s ‘End of Life’ guidance in England (NICE, 2009) and the fact that several jurisdictions have separate policies for dealing with expensive specialized services or drugs for rare conditions (Zamora et al, 2017).
The interesting issue that Voorhoeve discusses is that some individuals may wish to prioritize serious or life-threatening illnesses over all others, to the extent that they may support policies that would provide funding for treatments for all these conditions before any funding were devoted to conditions that they do not consider to be serious. He proposes two hypotheses that might explain this view and suggests how they might be tested. Like Voorhoeve (I suspect), my money would be on the hypothesis that he calls Aggregate Relevant Claims (Voorhoeve, 2014). I would therefore be in favour of the research programme that he proposes.
However, Voorhoeve also mentions a policy under discussion in the Netherlands, whereby public spending on the prevention and alleviation of ailments that impose only very small heath burdens is eliminated, independently of their cost-effectiveness (my emphasis), in order to focus public resources on averting more substantial burdens (CVZ 2012a,b). If the Netherlands were to implement this policy, it would be a real test of the extent to which the general public favours this approach over one more focused on cost-effectiveness, with the emphasis on maximizing total health gain from the available budget. In particular, it would be interesting to see how far down the gradient of ‘seriousness’ of health conditions the current budget would stretch, particularly if there were no limits on the finances devoted to expensive therapies for serious conditions, even if their potential for generating health gains were low.
Presumably the line between reimbursement and non-reimbursement will have to be drawn somewhere and refusal to reimburse some treatments will no doubt generate discussion and debate. The real test of the hypothesis is whether the rationing decisions taken under this policy are viewed as being more socially legitimate than those taken under the Oregon experiment (Morell, 1990) or taken in jurisdictions applying a utilitarian cost-effectiveness approach.
Read the full paper by Alex Voorhoeve in the May 2018 issue of Behavioural Public Policy here
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CVZ. 2012b. Technische rapportage ziektelast. Diemen: CVZ.
Drummond, M.F., de Pouvourville, G., Jones, E., Haig, J., Saba, G., Cawston, H. (2014) A comparative analysis of two contrasting European approaches for rewarding the value added by drugs for cancer: England versus France. Pharmacoeconomics, 32:5, 509-520. Doi: 10.1007/s40273-014-0144-z.
Morell, V. 1990. Oregon puts bold health plan on ice. Science 249: 468—71.
National Institute for Health and Care Excellence (NICE). Appraising life-extending, end of life treatments. NICE London, 2009.
Ottersen, T., R. Førde, M. Kakad, A. Kjellevold, H.O. Melberg, A. Moen, Å. Ringard,and O.F. Norheim. 2016. A new proposal for priority setting in Norway: Open and fair. Health Policy, online early http://dx.doi.org/10.1016/j.healthpol.2016.01.012
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Voorhoeve, A. 2014. How should we aggregate competing claims? Ethics 125: 64-87.
Voorhoeve, A. 2017 Small Benefits for Many or Large Benefits for a Few? Behavioural Public Policy (reference to added.)
Zamora B, Maignen F, O’Neill P, Mestre-Ferrandiz J, Garau M (2017). Comparing Access to Orphan Medicinal Products (OMPs) in the United Kingdom and other European countries. OHE Consulting Report. London, Office of Health Economics.