Jan Abel Olsen

Helicopters, hearts and hips: Using willingness to pay to set priorities for public sector health care programmes

The paper reports from a study that asked 150 interviewees their willingness to pay (WTP) in increased earmarked taxation for three different health care programmes: a helicopter ambulance service, more heart operations and more hip replacements. Reasons behind the stated WTP were asked for. Ordinary least squares regression analyses were used to analyse factors associated with WTP for each of the three programmes, and factors associated with the relative WTP for one programme compared with the total of the three. Comparisons were made of WTP for these programmes and the health outcome in terms of quality adjusted life years.

Theories of justice and their implications for priority setting in health care

The paper aims to show how three theories of distributive justice; utilitarianism, egalitarianism and maximum, can provide a clearer understanding of the normative basis of different priority setting regimes in the health service. The paper starts with a brief presentation of the theories, followed by their prescriptions for distribution, as illustrated with their respective preferred points on a utility possibility frontier. After this general discussion, attention is shifted from utils to health. The paper discusses how the recent Norwegian guidelines for priority setting can be understood in the light of the theories.

On what basis should health be discounted

The discount rate to be applied in health care programmes should be based on the time preference rate for health, and this same rate should be applied to costs as well. Due to the limited tradeability of health, when eliciting its time preference rate, the intertemporal choices must be framed in such a way as to resemble as closely as possible those facing health planners and decision makers.

The moral relevance of personal characteristics in setting health care priorities

This paper discusses the moral relevance of accounting for various personal characteristics when prioritising between groups of patients. After a review of the results from empirical studies, we discuss the ethical reasons which might explain-and justify-the views expressed in these studies. The paper develops a general framework based upon the causes of ill health and the consequences of treatment. It then turns to the question of the extent to which a personal characteristic-and the eventual underlying ethical justification of its relevance-could have any relationships to these causes and consequences. We attempt to disentangle those characteristics that may reflect a potentially relevant justification from those which violate widely accepted principles of social justice.

The insensitivity of 'willingness-to-pay' to the size of the good: New evidence for health care

This paper inquires into the existence of two types of scope insensitivity in health care; one deals with different numbers of patients treated from a programme, the other with different reductions in the risk of heart attack. Two empirical studies in Norway and Portugal were designed to measure the extent to which willingness-to-pay (WTP) varies with the size of health outcomes. Comparisons of WTP with different sizes of the goods were undertaken both across samples and within samples. The results showed no statistically significant differences in WTP with different sized health effects, something that casts doubt on the reliability of the WTP-method as an instrument for comparing the social values of competing health care programmes.

Aiding priority setting in health care: is there a role for the contingent valuation method?

The paper discusses some methodological and measurement aspects with the contingent valuation (CV) method which appear to create problems when eliciting preferences for the relative social valuation of alternative health care programmes. After pointing to biases which tend to exaggerate the true valuations, emphasis is placed on framing issues when applied to health care. Thereafter the paper discusses the extent to which preferences elicited through ones willingness to pay can be used to infer how the respondent would prioritize between the health care programmes in question. New empirical evidence is presented which suggest discrepancies between a CV ranking and the ranking expressed when making a direct ordinal comparison.

Societal views on orphan drugs: cross sectional survey of Norwegians aged 40 to 67

Objective To determine whether a general societal preference for prioritising treatment of rare diseases over common ones exists and could provide a justification for accepting higher cost effectiveness thresholds for orphan drugs. Design Cross sectional survey using a web based questionnaire. Setting Norway. Participants Random sample of 1547 Norwegians aged 40-67. Main outcome measure Choice between funding treatment for a rare disease versus a common disease and how funds should be allocated if it were not possible to treat all patients, for each of two scenarios: identical treatment costs per patient and higher costs for the rare disease. Respondents rated five statements concerning attitudes to equity on a five point Likert scale (5=completely agree). Results For the equal cost scenario, 11.2% (9.6% to 12.8%) of respondents favoured treating the rare disease, 24.9% (21.7% to 26.0%) the common disease, and 64.9% (62.6% to 67.3%) were indifferent. When the rare disease was four times more costly to treat, the results were, respectively, 7.4% (6.1% to 8.7%), 45.3% (42.8% to 47.8%), and 47.3% (44.8% to 49.8%). Rankings for attitude on a Likert scale indicated strong support for the statements “rare disease patients should have the right to treatment even if more expensive” (mean score 4.5, SD 0.86) and “resources should be used to provide the greatest possible health benefits” (3.9, 1.23). Conclusions Despite strong general support for statements expressing a desire for equal treatment rights for patients with rare diseases, there was little evidence that a societal preference for rarity exists if treatment of patients with rare diseases is at the expense of treatment of those with common diseases.

Treatment costs in hodgkin's disease: A cost-utility analysis

The aim of this study was to estimate costs of treatment for Hodgkins disease (HD) and the outcome in health in terms of quality-adjusted life-years (QALYs), and compare these to a constructed nontreatment alternative. All 55 patients treated for HD at the oncological unit of the University Hospital of Tromsø between 1985 and 1993 were included. The total treatment costs (medication, hospital stay, hospital hotel stay, radiotherapy, travelling, loss in production, i.e. work) were retrospectively estimated for all patients. In December 1994, the 49 survivors were sent a EuroQol questionnaire recording quality of life: 42 responded. The mean quality of life score was 0.78 on a 0-1 scale, and the mean total cost of treatment was pounds 12512. The total treatment costs were significantly higher in patients with advanced clinical stages of the disease (P = 0.0006), B-symptoms (fever, sweats, weight loss) (P = 0.0027) and relapse (P < 0.0001). The costs of one QALY (with production gains included and using a 10% discount rate) were estimated at pounds 1651. When excluding production gains and using a 5% discount rate, the figures became pounds 1327. This makes HD one of the most cost-effective malignancies to treat.

Trastuzumab in adjuvant breast cancer therapy. A model based cost-effectiveness analysis

Trastuzumab has shown activity in early breast cancer patients that overexpress HER2. Significant resources have to be allocated to finance this therapy, underlining the need for cost-effectiveness analysis. A model was set up, societal costs were calculated and the discount rate was 3%. Life expectancy data were based on the literature and prolonged according to qualified guess (10% and 20% absolute improvement in overall survival (OS)). The comparator was the FEC100 regimen. The median additional health care cost per patient treated was €33 597. The yielding cost per life year gained (LYG) was €15 341 with a 20% improved OS and €35 947 with 10% improved OS. The corresponding net health care cost per quality adjusted life year (QALY) was €19 176 and €44 934. Including all resource use the figures were €8148 and €30 290 per LYG. Sensitivity analyses documented survival gain, price of trastuzumab, production gain and discount rate to be the major factors influencing cost-effectiveness ratio. Trastuzumab is indicated cost effective in Norway.

Lumpectomy or mastectomy? Is breast conserving surgery too expensive?

In the last decade, breast cancer patients have enjoyed an increase inbreast conserving surgery (BCS). At present, modified radical mastectomy(MRM) and BCS offers equal expectations of survival. During the last fewyears, however, a drop in the frequency of BCS has been reported by severalauthors. Is this new trend due to economic concerns? To clarify the costs ofbreast cancer therapy (stage I and II), we review the literature and includea cost-utility and a cost-minimisation analysis comparing MRM and BCS.The treatment cost (per patient) of BCS and MRM in Norway was calculated at