Wbf Brouwer

Balancing equity and efficiency in the Dutch basic benefits package using the principle of proportional shortfall

Economic evaluations are increasingly used to inform decisions regarding the allocation of scarce health care resources. To systematically incorporate societal preferences into these evaluations, quality-adjusted life year gains could be weighted according to some equity principle, the most suitable of which is a matter of frequent debate. While many countries still struggle with equity concerns for priority setting in health care, the Netherlands has reached a broad consensus to use the concept of proportional shortfall. Our study evaluates the concept and its support in the Dutch health care context. We discuss arguments in the Netherlands for using proportional shortfall and difficulties in transitioning from principle to practice. In doing so, we address universal issues leading to a systematic consideration of equity concerns for priority setting in health care. The article thus has relevance to all countries struggling with the formalization of equity concerns for priority setting.

Are all health gains equally important? An exploration of acceptable health as a reference point in health care priority setting.

BackgroundAccumulating evidence suggests that members of society prefer some QALY gains over others. In this paper, we explore the notion of acceptable health as a reference point in assessing the value of health gains. The value of health benefits may be assessed in terms of their position relative to this reference level, benefits above the level of acceptable health being valued differently from benefits below this level. In this paper we focus on assessing the level of acceptable health at different ages and associations with background variables.MethodsWe recruited a sample of the adult population from the Netherlands (n = 1067) to investigate which level of health problems they consider to be acceptable for people aged 40 to 90, using 10-year intervals. We constructed acceptable health curves and associated acceptable health with background characteristics using linear regressions.ResultsThe results of this study indicate that the level of health problems considered acceptable increases with age. This level was associated with respondents’ age, age of death of next of kin, health and health behaviour.ConclusionsOur results suggest that people are capable of indicating acceptable levels of health at different ages, implying that a reference point of acceptable health may exist. While more investigation into the measurement of acceptable health remains necessary, future studies may also focus on how health gains may be valued relative to this reference level. Gains below the reference point may receive higher weight than those above this level since the former improve unacceptable health states while the latter improve acceptable health states.

Health or Happiness? A Note on Trading Off Health and Happiness in Rationing Decisions

BACKGROUND Economic evaluations typically value the effects of an intervention in terms of quality-adjusted life-years, which combine length and health-related quality of life. It has been suggested that economic evaluations should incorporate broader outcomes than health-related quality of life. Broader well-being, for instance measured as happiness, could be a better measure of the overall welfare effects in patients because of treatment. An underexplored question is whether and how people trade off information on health and broader outcomes from treatment in rationing decisions. OBJECTIVES This article presents the results of a first experiment aimed at exploring such trade-offs between health and happiness. METHODS We used a Web-based questionnaire in a representative sample of the public from the Netherlands (N = 1015). People made choices between two groups of patients differing in terms of their health and happiness levels before treatment and gains from treatment. RESULTS The results showed that about half the respondents were willing to discriminate between patient groups on the basis of their health and happiness levels before and after treatment. In the trader group, health gains were considered somewhat more important than happiness gains. CONCLUSIONS Our findings suggest that both health and happiness levels of patients may play a role in priority setting.

PMD46 PROCESS UTILITY DERIVED FROM PROVIDING INFORMAL CARE

OBJECTIVE: The objective of this study was to develop and validate a series of schizophrenia specific risk adjustment cost models. METHODS: Georgia Medicaid claims data linked with institutional inpatient data for 21,602 continuous eligible persons suffering from schizophrenia was used to build a prospective diagnosis-based, a demographic-based, a drug-based, and a combined risk adjustment cost model. ICD-9-CM and drug category classifications were derived from the literature and supplemented by an expert panel. Variables were screened and cost weights were derived empirically in a random 50% training sample using a robust a weighted HeuberWhite regression model and validated by expert panel review, bootstrapping methods, and assessing indices of discrimination in a 50% validation sample. Model calibration and correlations of errors with policy relevant groups were also estimated. RESULTS: Measures of discrimination (R2) varied between 16.4% for the ICD-9CM based model to 21.8% for the combined model for trimmed total cost and varied between 4.9% to 11.3% for mental health costs in the validation sample. Risk adjustment models based on drug or ICD-9-CM information discriminated costs equally well and the combined models outperformed both drug and ICD-9-CM based models. A simple model using prior year costs combined with demographic covariates had R2s > 40% for both mental health and total costs. CONCLUSIONS: The drug and ICD-9-CM based models performed equally well and either can be used with equal confidence depending on data availability. The combined models performed better than either the ICD-9-CM or drug based models indicating that drug exposure information can compliment more traditional approaches. Health services researchers wishing to control for differences in comorbidity and severity that influence cost should always consider including prior utilization (costs) since prior year costs were vastly superior predictors of costs.