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Cost effectiveness as argumentfor reimbursement in prevention

• Jan J. v. Busschbach, Ph.D.• Erasmus MC

– Institute for Medical Psychology and PsychotherapyPO Box 17383000 DR Rotterdam+31 10 4087807J.vanbusschbach@erasmusmc.nl

• Psychotherapeutic centre 'De Viersprong’– PO Box 7

4660 AA Halsteren+ 31 164 632200Jan.Busschbach@deviersprong.nl

• Presentations can be found at– http://www.xs4all.nl/~jannetvb/busschbach/

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Health Economics

• Comparing different allocations– Should we spent our money on

» Wheel chairs

» Screening for cancer

» Preventing alcohol abuse

– Comparing costs

– Comparing outcome

• Relate costs to outcome– Cost per outcome

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Car economics

• Should we spend our money on a– Suzuki Alto 1.0

– BMW 316

– Comparing costs

– Comparing outcome

• Relate costs to outcome– Cost per outcome

– Cost per kilometer

» Suzuki Alto 1.0

» BMW 316

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Car league table

Car € / Km Car € / Km

Suzuki Alto 1.0 0.24 Hyundai Lantra 1.5 0.47

Daihatsu Cuore 1.0 0.27 Opel Vectra 1.6 0.53

Hyundai Atos Multi 1.0 0.27 Citroën Xantia 1.8i 0.55

Renault Twingo 1.2 inj 0.28 Mazda 626 2.0 0.58

Daewoo Matiz 0.33 BMW 316 0.74

Cost per kilometre including gas, maintenance, debit, etc. Price level 2002.Calculations based on over 2,5 years use and 40.000 km.(Consumentenbond, Augustus 2003)

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Health Economics

• Comparing costs– Inside health care

– Outside health care

• Comparing outcome– Life years

– Quality of life

» Quality Adjusted Life Years

» QALYs

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QALY league tableIntervention $ / QALYGM-CSF in elderly with leukemia 235,958

EPO in dialysis patients 139,623

Lung transplantation 100,957

End stage renal disease management 53,513

Heart transplantation 46,775

Didronel in osteoporosis 32,047

PTA with Stent 17,889

Breast cancer screening 5,147

Viagra 5,097

Treatment of congenital anorectal malformations 2,778

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Additional arguments in car economic

• When people are facing the bad cost effectiveness of their own car...

• Denial– Validity and ad hoc arguments

» My car is not on the list...» I drive more kilometres...» I drive a diesel...

• The use additional arguments– The sensation of driving– Beauty– Space– Prestige

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Additional arguments in health care reimbursement

• If economics evaluation fails– Reimbursement of lung transplantation

– No reimbursement of Viagra

• Denial – 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 in QALYs

– 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 arguments representsburden of disease

• Severity of illness– Looking forwards

» Prospective health– lung transplantation: it is unethical to let someone die

» Rule of rescue» Necessity of care

• Faire innings – Looking backwards

» Total health– Viagra: when you get older, erectile dysfunction is not longer

considered a disease» You had you share of the cake» Does not apply for younger man

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Combining “severity of illness” with “faire innings” (Elly Stolk)

Proportional short fall

Onychomycosis 0.02Osteoporosis 0.08Symptomatic BPH 0.09Hypertension 0.26High Cholesterol 0.28Arteriosclerosis 0.55COPD 0.61Pneumococcal pneumonia 0.82Pulmonary hypertension 0.96Non-Hodgkin Lymphoma 0.97

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CE-ratio by burden of disease

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Burden of disease and prevention

• Severity of illness– The potential patient is not ill (yet)

» Focuses on the patients that die now, not in the future

» Discounting

• Fair innings– The future patients is still collecting his faire innings

• Burden of disease is not in favour of prevention– Prevention has to be more cost effective than cure

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Can we escape the negative influence of burden of disease?

• Define conservative target population– Flu vaccination is to prevent mortality in elderly

» Not to prevent mobility

– Alcohol abuse programs is not for the common men

» Low burden of disease in normal life

• Otherwise dilution of burden...– Explains reimburcement when media focus on victims

» meningitis vaccination

• Different target as for cost effectiveness– Cost effectiveness: treated population

– Burden of disease: main target population

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Conclusion

• Cost effectiveness arguments exits next to other arguments

• The burden of disease argument is negative for prevention

– Prevention has to be more cost effective than cure

• Focus burden of disease studies on those patient groups for who it really matters

– To prevent the erosion of the argument