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QALY, Burden of Disease andBudget Impact
Jan J.V. Busschbach, Ph.D. Erasmus MC, Rotterdam, The Netherlands
www.Busschbach.nl
Issue Panels – Session IITuesday, May 22, 2007 2:00 PM – 3:00 PM
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3600 Citations in PubMed
1980[pdat] AND (QALY or QALYs)
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1980 1985 1990 1995 2000 2005 2010
Pu
blic
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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
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Uti
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TTO
PTO
Susan Robinson, iHEA 2001Also: Report Health Services Management Centre, Birmingham
Psychometrics
“If we look at TTO and PTO… …we see that one of them is wrong”
Paul Kind, iHEA 2001
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TTO
PTO
Susan Robinson, iHEA 2001
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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PTO
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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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20000
40000
60000
80000
Severity of disease
Co
st
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AL
Y
20,000 per QALY
Increase threshold
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)
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?
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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
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Proportional
short fall
Intermediate position
Fair innings Looking backwards
Total health
Severity of illness Looking forwards
Prospective health
Proportionalshort fall Intermediate
Health patient A
t
Prospective health patient A
Birth
Now
Fair innings patient A
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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
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Accepted Rejected
High burden Low burden
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 interpretation:Budget 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
