Abstract
New medical technologies that prolong life result in additional health care use in life years gained. Some of these costs in life years gained are considered to be related to the intervention while other costs are considered unrelated. Here, we argue that ignoring these so-called future medical costs in cost effectiveness analysis is contrary to common sense, results in lost health and fails to inform decision makers for whom cost effectiveness is supposed to serve.
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Background
Health services in most of the developed world are under increasing strain as populations age: this is no less true for being a cliché [1, 2]. An important driver of growing health care expenditures is the introduction of new medical technology (often targeted at the elderly) [3]. Although some medical technology has made important contributions to improvements in population health, not all new technologies result in health gains at ‘acceptable’ prices. Cost effectiveness analysis (CEA) aims to inform decision makers at what price new technologies yield health gains.
The most notable and systematic use of CEA is in England, where the National Institute for Health and Clinical Excellence (NICE) has been established to assess whether new technologies within health care yield sufficient value for money to allow routine use within the English National Health Service (NHS). Consequently, NICE guidance with respect to the use of health care technologies, not only their methodological guidance on how to assess health care technologies have been highly influential in England, but also serve as role model for other countries wishing to use CEA results in decision making. When developing guidance, cost effectiveness is considered explicitly by NICE in the so-called assessment phase in which evidence on cost and effects is gathered, and subsequently in the appraisal phase in which there is a deliberation upon the gathered evidence [4]. An intervention is deemed cost effective by NICE if ‘its health benefits are greater than the opportunity costs of programmes displaced to fund the new technology, in the context of a fixed NHS budget. In other words, the general consequences for the wider group of patients in the NHS are considered alongside the effects for those patients who may directly benefit from the technology’ [4]. In this article we question whether the current guidelines for health technology assessment used by NICE are appropriately given in this definition of cost effectiveness. The point we want to take issue with, in particular, is the handling of “unrelated future medical costs” in cost effectiveness analysis. These are now explicitly excluded from these analyses in current guidelines, but, as we will argue, they should be included to support better decisions [5].
Future costs and cost-effectiveness analysis
Medical interventions that increase life expectancy of patients may create additional consumption of medical goods and services in so-called ‘added life years’. Added years are those years that would not have been lived without the intervention. A part of this medical consumption in added years is directly related to the intervention. In case of a successful heart transplantation, costs of visiting the cardiologist in life years gained are considered related. These costs are typically included in economic analyses. Other costs in added years are not directly related to the intervention and are termed costs of ‘unrelated medical care’. This would for instance be the case for costs resulting in dementia care in added life years after the same heart transplantation. These costs are typically excluded from economic analyses. However, given the increased survival of older patients and a high concentration of spending in the elderly, it is likely that life-prolonging technologies create a lot of ‘unrelated’ health care use in life years gained. A recent study suggested that a substantial part of the rise in emergency admissions to hospitals can be explained by improved survival of patients from previous admissions and, therefore, creation of a new set of frail patients, who would in previous years have died [6].
Whether we should worry about unrelated costs in added life years in cost effectiveness analysis when we decide on a life-prolonging technology is currently much debated [7, 8]. To better understand the relevance of unrelated medical costs when deciding on health care interventions, we invite readers to consider the story in Box 1 where we present a stylized example relevant for individual decision making. If you, the reader, had to give advice to the family about this difficult choice, would you ignore the dialysis costs in informing their decision about chemotherapy on the grounds that they are “unrelated”?
Guidelines
Whether unrelated costs are taken into account in economic evaluations in practice crucially depends on guidelines for economic evaluations. To ensure that economic evaluations are performed in a sound way, aligning with the goals and constraints of the NHS, they should be conducted by adhering to guidelines such as those developed by NICE [4]. With respect to the inclusion of future costs, current NICE guidelines for technology assessment advise that “Costs related to the condition of interest and incurred in additional years of life gained as a result of treatment should be included in the reference-case analysis. Costs that are considered to be unrelated to the condition or technology of interest should be excluded”. The Dutch Health Care Institute had identical advice regarding unrelated medical care as NICE, but recently recognized the inconsistency of ignoring these real costs and decided to change these guidelines to encourage inclusion of all future medical costs [14]. Note that the Dutch are not the first to recommend inclusion of these costs as Swedish guidelines for cost-effectiveness analyses have always recommended inclusion. Furthermore, recently updated guidance from the US panel on cost effectiveness also recommends inclusion of future unrelated medical costs [15]. As a consequence of current NICE guidance, costs of dementia treatment in life years gained would be ignored in an economic evaluation of cancer treatment. The consequence is that the health losses as a result of disinvestment in older technologies might be greater than the health gains of investing in newer technologies resulting in balanced health losses.
Recent research has shown that the value for money as measured by the incremental cost-effectiveness ratio (ICERFootnote 1) is an important determinant whether a technology will be recommended by NICE [16]. On average, an increase of the ICER of £1000 decreases the odds of being adopted by about 7% [16]. Including future unrelated costs can have a big impact on the incremental cost-effectiveness ratio (ICER). Although the numerical impact may differ from intervention to intervention, in general, the impact of unrelated medical care will be bigger for life-saving interventions targeted at elderly and frail people. While for interventions that do not extend life, the ICER would be unaffected, including future unrelated medical costs which could increase the ICER by thousands of pounds for interventions that extend life considerably, but where life years gained are spent in poor health. Therefore, a change in NICE guidance could have a substantial impact on decisions. Box 2 gives an example which illustrates the impact of future unrelated costs for decisions reached by NICE.
Ethical considerations
Could the analysis which we present above have ethically undesirable implications? It is possible to construct examples where including unrelated future costs in analysis can produce conclusions which are hard to swallow—for example when considering life-extending interventions in institutionalised and/or chronically ill patients (see Box 3).
Conclusion
The upcoming pressures on the healthcare system from our ageing population will be intense. It is more important than ever that decisions about resource allocation are made in a spirit of stewardship, informed by robust common sense. We argue that current technical guidance on unrelated future costs in many countries does not meet this standard, and NICE should set an example and follow the Dutch change in guidelines, and recommend inclusion of future unrelated medical costs in health technology assessments. For some patient groups, including future unrelated medical costs may imply a huge increase in the ICER for life-prolonging technologies and thereby trigger difficult ethical debates. However, NICE stresses that decisions should be made in a way which is procedurally fair, which allows for such arguments to be raised and deliberated upon when appraising the evidence [20]. The task of the analyst in these situations is to provide decision makers with a full picture of the relevant consequences for the healthcare budget now and in the future. Expert advisers—whether to a family or to a nation—have the responsibility to present all relevant information to whom society has seen fit to entrust with decision-making responsibility.
Notes
A central element of an economic evaluation is an incremental cost effectiveness ratio (ICER) which indicates how much has to be paid for an additional QALY by adopting a new intervention relative to some relevant comparator (e.g. current care). In the UK, the ICER is a ratio that is derived by dividing the additional costs falling, roughly speaking, on the NHS and also the Personal Social Services (PSS) budget by the additional population health gains measured in terms of quality adjusted life years (QALYs).
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van Baal, P., Morton, A., Meltzer, D. et al. Future unrelated medical costs need to be considered in cost effectiveness analysis. Eur J Health Econ 20, 1–5 (2019). https://doi.org/10.1007/s10198-018-0976-0
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DOI: https://doi.org/10.1007/s10198-018-0976-0