How can Societal Concerns for Fairness be Integrated into Economic Evaluations? Towards Cost-Value Analysis in Health Care

Introduction

Thank you very much for inviting me here. It is nice to be in Berlin.

I first want to say a little about my personal background. I started twenty years ago from the inside of health economics as a member of the EuroQol Group, which has developed the EQ-5D, a tool for valuing health states for use in QALY analyses. Then I gradually moved into criticising QALYs and developing an alternative. Most recently, I participated at a consensus workshop on QALYs organised in Philadelphia in November 2007 by ISPOR, and I am a member of IQWiG's International Economic Methods Panel.

The health care system here in Germany is different from the one we have in Norway and in England. For instance, you have an insurance system, which is not exactly the same as our national health services, but basic issues, I think, are the same. We have limited resources and we want to respect population preferences. By the latter I don’t mean just taking them at face value without critical judgement of them. Ethical discussion and theory is essential to determining what we as a society want, but that includes eliciting the preferences of the population.

When we ask ourselves what we want, there are two perspectives that it is useful to bear in mind. One is, what is our self-interest as individuals, behind a veil of ignorance about which illnesses we could get in the future. But most people don’t ask only that question. They are also members of a community, where they are interested in being part of a system that is fair, that treats others in a way that is ethical. We care for others. My interest is in how we can include the caring-for-others-perspective in formal economic evaluation.

I stress that I see my job here as to describe economic evaluation, not to say exactly what position or role it should have in decision making. That is a different issue. We need to consider carefully what usefulness there is in the methods that economists develop.

I will describe two methods: First, cost-utility analysis, which uses the QALY as a unit of measurement of benefit, and second, the possibility of doing something with that approach to perhaps bring it closer to the ethical preferences that society holds when it comes to allocating scarce resources.

Literatur

• 1 Daniels N. Just Health Care. Cambridge University Press 1985
• 2 Dolan P, Cookson R. Measuring preferences over the distribution of health benefits. Mimeo. University of York, CHE 1998
• 3 Nord E. Health status index models for use in resource allocation decisions.  Int J Techn Ass in Health Care. 1996;  12 31-44
• 4 Nord E. Cost-value analysis in health care. Cambridge Universtity Press 1999
• 5 Nord E, Pinto JL, Richardson J. et al . Incorporating concerns for fairness in numerical valuations of health programmes.  Health Economics. 1999;  8 25-39
• 6 Nord E, Enge A, Gundersen V. Is the Value of treatment proportional to the size of the health gain?. Health Economics 2009 (in press)
• 7 Olsen JA. Person vs. years: Two ways of eliciting implicit weights.  Health Economics. 1994;  3 39-46
• 8 Pinto JL, Perpinan JMA. Health state after treatment: A reason for discrimination?. Health Economics 1998
• 9 Ubel P, Loewenstein G, Scanlon D. et al . Individual utilities are inconsistent with rationing choices.  Med Dec Mak. 1996;  16 108-116
• 10 Ubel P, Richardson J, Pinto JL. Life saving treatments and disabilities.  Int J Techn Ass in Health Care. 1999;  15 738-748

Correspondence