An instrument for measuring the social willingness to pay for health state improvement

Rationale, conceptual issues, and resultant protocol for a mixed methods Person Trade Off (PTO) and qualitative study to estimate and understand the relative value of gains in health for children and young people compared to adults

BACKGROUND

Economic evaluation of healthcare typically assumes that an identical health gain to different patients has the same social value. There is some evidence that the public may give greater value to gains for children and young people, although this evidence is not always consistent. We present a mixed methods study protocol where we aim to explore public preferences regarding health gains to children and young people relative to adults, in an Australian setting.

METHODS

This study is a Person Trade Off (PTO) choice experiment that incorporates qualitative components. Within the PTO questions, respondents will be asked to choose between treating different groups of patients that may differ in terms of patient characteristics and group size. PTO questions will be included in an online survey to explore respondent views on the relative value of health gains to different age groups in terms of extending life and improving different aspects of quality of life. The survey will also contain attitudinal questions to help understand the impact of question style upon reported preferences. Additionally, the study will test the impact of forcing respondents to express a preference between two groups compared with allowing them to report that the two groups are equivalent. One-to-one 'think aloud', semi-structured interviews will be conducted to explore a sub-sample of respondents' motivations and views in more detail. Focus groups will be conducted with members of the public to discuss the study findings and explore their views on the role of public preferences in health care prioritisation based on patient age.

DISCUSSION

Our planned study will provide valuable information to healthcare decision makers in Australia who may need to decide whether to pay more for health gains for children and young people compared with adults. Additionally, the methodological test of forcing respondent choice or allowing them to express equivalence will contribute towards developing best practice methods in PTO studies. The rationale for and advantages of the study approach and potential limitations are discussed in the protocol.

Willingness to pay for a quality-adjusted life year: a systematic review with meta-regression

The use of a threshold for cost-utility studies is of major importance to health authorities for making the best allocation decisions for limited resources. Regarding the increasing number of studies worldwide that seek to establish a value for a quality-adjusted life year (QALY), it is necessary to review these studies to provide a global insight into the literature. A systematic review on willingness to pay (WTP) studies focusing on QALY was conducted in eight databases up to June 26, 2020. From a total of 9991 entries, 39 studies were selected, and 511 observations were extracted for the meta-analysis using the ordinary least squares method. The results showed a predicted mean empirical value of $52,619.39 (95% CI 49,952.59; 55,286.19) per QALY in US dollars for 2018. A 1% increase in income led to an increase of 0.6% in the WTP value, while a 1-year increase in respondent age led to a decrease of 3.3% in the WTP value. Sex, education level and employment status had significant effects on WTP. Compared to face-to-face interviews, surveys conducted by the internet or telephone were more likely to have a significantly higher value of WTP per QALY, while out-of-pocket payment tended to lower the value. The prediction made for the province of Quebec, Canada, provided a QALY value of approximately USD $98,450 (CAD $127,985), which is about 2.3 times its gross domestic product (GDP) per capita in 2018. This study is consistent with the extant literature and will be useful for countries that do not yet have a preference-based survey for the value of a QALY.

Evaluating Discrete Choice Experiment Willingness to Pay [DCE-WTP] analysis, and Relative Social Willingness to Pay [RS-WTP] analysis in a Health Technology Assessment of a treatment for an ultra-rare childhood disease [CLN2]

BACKGROUND

: Conventional cost-effectiveness analysis [CEA] using cost per QALY thresholds may counteract other incentives introduced to foster development of treatments for rare and ultra-rare diseases. Therefore, alternative economic evaluation methods were explored, namely Discrete Choice Experiment Willingness to Pay (DCE-WTP) and Relative Social Willingness to Pay (RS-WTP), to value interventions for an ultra-rare childhood disease, Neuronal Ceroid Lipofuscinosis type 2 (CLN2).

RESEARCH DESIGN AND METHODS

Treatment for CLN2 was valued from a citizen's ("social") perspective using DCE-WTP and RS-WTP in a survey of 4,009 United Kingdom [UK] adults. Three attributes (initial quality of life, treatment effect, and life expectancy) were used in both analyses. For DCE-WTP a cost attribute (marginal income tax increase) was also included. Optimal econometric models were identified.

RESULTS

DCE-WTP indicated that UK adults are willing to pay incremental increases through taxation for improvements in CLN2 attributes. RS-WTP identified a willingness to allocate >40% of a pre-assigned healthcare budget to prevent child mortality and approximately 15% for improved health status.

CONCLUSIONS

Both techniques illustrated substantive social WTP for CLN2 interventions, despite the small number of children benefitting. This highlights a gap between UK citizens' willingness to spend on rare disease interventions and current funding policies.

How Much Does It Cost to Research and Develop a New Drug? A Systematic Review and Assessment

BACKGROUND

Debate over the viability of the current commercial research and development (R&D) model is ongoing. A controversial theme is the cost of bringing a new molecular entity (NME) to market.

OBJECTIVE

Our aim was to evaluate the range and suitability of published R&D cost estimates as to the degree to which they represent the actual costs of industry.

METHODS

We provided a systematic literature review based on articles found in the Pubmed, Embase and EconLit electronic databases, and in a previously published review. Articles published before March 2020 that estimated the total R&D costs were included (22 articles with 45 unique cost estimates). We included only literature in which the methods used to collect the information and to estimate the R&D costs were clearly described; therefore, three reports were excluded. We extracted average pre-launch R&D costs per NME and converted the values to 2019 US dollars (US$) using the gross domestic product (GDP) price deflator. We appraised the suitability of the R&D estimated costs by using a scoring system that captures three domains: (1) how success rates and development time used for cost estimation were obtained; (2) whether the study considered potential sources contributing to the variation in R&D costs; and (3) what the components of the cost estimation were.

RESULTS

Estimates of total average capitalized pre-launch R&D costs varied widely, ranging from $161 million to $4.54 billion (2019 US$). Therapeutic area-specific estimates were highest for anticancer drugs (between $944 million and $4.54 billion). Our analysis identified a trend of increasing R&D costs per NME over time but did not reveal a relation between cost estimates and study ranking when the suitability scores were assessed. We found no evidence of an increase in suitability scores over time.

CONCLUSION

There is no universally correct answer regarding how much it costs, on average, to research and develop an NME. Future studies should explicitly address previously neglected variables, which likely explain some variability in estimates, and consider the trade-off between the transparency and public accessibility of data and their specificity. Use of our proposed suitability scoring system may assist in addressing such issues.

Mental health: The burden of social stigma

The burden of mental health has two facets, social and psychological. Social stigma causes individuals who suspect to be suffering from a mental condition to conceal it, importantly by seeking care from a nonspecialist provider willing to diagnose it as physical disease. In this way, social stigma adds to both the direct and indirect cost of mental health. A microeconomic model depicting an individual who searches for an accommodating provider leads to the prediction that individuals undertake more search in response to a higher degree of social stigma. However, this holds only in the absence of errors in decision-making, typically as long as mental impairment is not too serious. While government and employers have an incentive to reduce the burden of social stigma, their efforts therefore need to focus on persons with a degree of mental impairment that still allows them to avoid errors in pursuing their own interest.

Determining Value in Health Technology Assessment: Stay the Course or Tack Away?

The economic evaluation of new health technologies to assess whether the value of the expected health benefits warrants the proposed additional costs has become an essential step in making novel interventions available to patients. This assessment of value is problematic because there exists no natural means to measure it. One approach is to assume that society wishes to maximize aggregate health, measured in terms of quality-adjusted life-years (QALYs). Commonly, a single 'cost-effectiveness' threshold is used to gauge whether the intervention is sufficiently efficient in doing so. This approach has come under fire for failing to account for societal values that favor treating more severe illness and ensuring equal access to resources, regardless of pre-existing conditions or capacity to benefit. Alternatives involving expansion of the measure of benefit or adjusting the threshold have been proposed and some have advocated tacking away from the cost per QALY entirely to implement therapeutic area-specific efficiency frontiers, multicriteria decision analysis or other approaches that keep the dimensions of benefit distinct and value them separately. In this paper, each of these alternative courses is considered, based on the experiences of the authors, with a view to clarifying their implications.

Health technology assessment (HTA) and economic evaluation: efficiency or fairness first

The economic evaluation which supports Health Technology Assessment (HTA) should inform policy makers of the value to society conferred by a given allocation of resources. However, neither the theory nor practise of economic evaluation satisfactorily reflect social values. Both are primarily concerned with efficiency, commonly conceptualised as the maximisation of utility or quality adjusted life years (QALYs). The focus is upon the service and the benefits obtained from it. This has resulted in an evaluation methodology which discriminates against groups and treatments which the population would like to prioritise. This includes high cost treatments for patients with rare diseases. In contrast with prevailing methods, there is increasing evidence that the public would prefer a fairness-focused framework in which the service was removed from centre stage and replaced by the patient. However methods for achieving fairness are ad hoc and under-developed. The article initially reviews the theory of economic evaluation and argues that its focus upon individual utility and efficiency as defined by the theory omits potentially important social values. Some empirical evidence relating to population values is presented and four studies by the first author are reviewed. These indicate that when people adopt the social perspective of a citizen they have a preference for sharing the health budget in a way which does not exclude patients who require services that are not cost effective, such as orphan medicinal products (OMP's) and treatments for patients with ultra-rare diseases (URD's).

Sharing and the Provision of "Cost-Ineffective" Life-Extending Services to Less Severely Ill Patients

BACKGROUND

Cost-utility analysis prioritizes services using cost, life-years, and the health state utility of the life-years. Nevertheless, a significant body of evidence suggests that the public would prefer more variables to be considered in decision making and at least some sharing of the budget with services for severe conditions that are not cost-effective because of their high cost.

OBJECTIVES

To examine whether this preference for sharing persists for less severe conditions when both cost effectiveness and illness severity would indicate that resources should be allocated to other services.

METHODS

Survey respondents were asked to divide a budget between two patients facing life-threatening illnesses. The severity of the illnesses differed and the price of treatment was varied.

RESULTS

Sharing occurred in all scenarios including scenarios in which the illness was less severe and services were not cost-effective. Results are consistent with behavior commonly observed in other contexts.

CONCLUSIONS

Results suggest that sharing per se is important and that the public would support some funding of cost-ineffective services for less severe health problems.

Budgetary Impact and Cost Drivers of Drugs for Rare and Ultrarare Diseases

OBJECTIVES

To review recent studies reporting health care expenditures (budgetary impact) for orphan medicinal products (OMPs) in Europe and to contribute to our understanding of the cost drivers of nononcological OMPs by means of an empirical analysis in Germany.

METHODS

A systematic search for relevant studies on rare diseases was conducted in PubMed and Embase (until December 2016). In addition, annual treatment costs of nononcological OMPs in Germany were analyzed with respect to five explanatory variables: total prevalence of disease, prevalence with added benefit, availability of alternative treatments for the same indication, extent/probability of treatment benefit, and evidence for a treatment effect on mortality.

RESULTS

A total of nine studies with specific estimates of the budget impact of OMPs for a total of 11 countries were identified; one study addressed specifically ultrarare diseases. Annual per-capita spending for OMPs ranges from €1.32 in Latvia to €16 in France. Per-patient annual treatment costs vary between €27,811 and €1,647,627 in Germany. On the basis of the German data set, the regression analysis shows that log prevalence has a significant inverse relationship with log annual treatment cost. In this model, doubling the prevalence leads to a 43% decrease in annual treatment cost.

CONCLUSIONS

Despite per-patient annual treatment costs ranging up to several hundreds of thousands of euros for some OMPs, per-capita spending for OMPs is relatively small. In this study an inverse relationship between prevalence and annual treatment costs was found.

Does a patient's health potential affect the social valuation of health services?

Background

Patients with a permanent impairment may be unable to reach full health. Consequently health services which cure illnesses which are unrelated to the impairment may increase health less than services for patients with no impairment. While it has been argued that this should not lead to discrimination against impaired patients there is little evidence to determine whether this equity-efficiency trade-off is consistent with social values.

Objectives

To measure the effect of permanent impairment upon the social valuation of services for unrelated illnesses.

Methods

Social valuations of services for illnesses associated with mobility, depression or pain were assessed and compared for patients with and without a permanent impairment using the Relative Social Willingness to Pay (RS-WTP) instrument. The maximum valuation of services for impaired patients was also compared with the maximum utility which could be gained when utility was measured using three multi attribute utility instruments.

Results

Curing the illness of impaired patients was valued 8–11 percent less than the cure of patients with no impairment. Discrimination decreased as the severity of the illness increased. Valuation of health states using the utility instruments implied significantly greater discrimination than the social valuations using the RS-WTP instrument.

Conclusions

Health services are valued less highly when a patient’s health potential is impaired. However discrimination is significantly less than would occur if the value of the services were limited to the value of the health state causing the impairment. The argument for disregarding a patient’s limited health potential when resources are allocated therefore receives some support from social valuations but the case for completely equal treatment depends upon additional ethical arguments.

How important is severity for the evaluation of health services: new evidence using the relative social willingness to pay instrument

The 'severity hypothesis' is that a health service which increases a patient's utility by a fixed amount will be valued more highly when the initial health state is more severe. Supporting studies have employed a limited range of analytical techniques and the objective of the present paper is to test the hypothesis using a new methodology, the Relative Social Willingness to Pay. Three subsidiary hypotheses are: (1) that the importance of the 'severity effect' varies with the type of medical problem; (2) that the relationship between value and utility varies with the severity of the initial health state; and (3) that there is a threshold beyond which severity effects are insignificant. For each of seven different health problems respondents to a web-based survey were asked to allocate a budget to five services which would, cumulatively, move a person from near death to full health. The time trade-off utilities of health states before and after the service were estimated. The social valuation of the service measured by the budget allocation was regressed upon the corresponding increase in utility and severity as measured by the pre-service health state utility. Results confirm the severity hypothesis and support the subsidiary hypotheses. However, the effects identified are quantitatively significant only for the most severe health states. This implies a relatively limited redistribution of resources from those with less severe to those with more severe health problems.

Age Weights for Health Services Derived from the Relative Social Willingness-to-Pay Instrument

The effect of a patient's age on the social valuation of health services remains controversial, with empirical results varying in magnitude and implying a different age-value profile. This article employs a new methodology to re-examine these questions. Data were obtained from 2 independent Web-based surveys that administered the Relative Social Willingness to Pay instrument. In the first survey, the age of the patient receiving a life-saving service was varied. Patients were left with either poor mental or physical health. In the second survey, patient age was varied for a service that fully cured the patient's poor mental or physical health. In total, therefore, 4 sets of age weights were obtained: weights for life-extending services with poor physical or mental health outcomes and weights for quality-of-life improvement for patients in poor mental or physical health. Results were consistent. Increasing age was associated in each case with a monotonic decrease in the social valuation of the services. The decrease in value was quantitatively small until age 60 years. By age 80 years, the social value of services had declined by about 50%. The decline commenced at an earlier age in the context of physical health, although the magnitude of the decrement by age 80 years was unrelated to the type of service. With 1 exception, there was little difference in the valuation of services by the age of the survey respondent. Respondents aged >60 years placed a lower, not higher, value on quality-of-life improvement for elderly individuals than other respondents. There was no difference in the valuation of life-extending services.

Willingness to pay per quality-adjusted life year for life-saving treatments in Thailand

OBJECTIVE

To estimate the willingness to pay (WTP) per quality-adjusted life year (QALY) value for life-saving treatments and to determine factors affecting the WTP per QALY value.

DESIGN

A cross-sectional survey with multistage sampling and face-to-face interviews.

SETTING

General population in the southern part of Thailand.

PARTICIPANTS

A total of 600 individuals were included in the study. Only 554 (92.3%) responses were usable for data analyses.

OUTCOME MEASURE

Participants were asked for the maximum amount of WTP value for life-saving treatments by an open-ended question. EQ-5D-3L and visual analogue scale (VAS) were used to estimate additional QALY.

RESULTS

The amount of WTP values varied from 0 to 720,000 Baht/year (approximately 32 Baht=US$1). The averages of additional QALY obtained from VAS and EQ-5D-3L were only slightly different (0.872 and 0.853, respectively). The averages of WTP per QALY obtained from VAS and EQ-5D-3L were 244,720 and 243,120 Baht/QALY, respectively. As compared to male participants, female participants were more likely to pay less for an additional QALY (p=0.007). In addition, participants with higher household incomes tended to have higher WTP per QALY values (p<0.001).

CONCLUSIONS

Our study added another WTP per QALY value specifically for life-saving treatments, which would complement the current cost-effectiveness threshold used in Thailand and optimise patient access to innovative treatments or technologies.

A systematic review of studies eliciting willingness-to-pay per quality-adjusted life year: does it justify CE threshold?

BACKGROUND

A number of studies have been conducted to estimate willingness to pay (WTP) per quality-adjusted life years (QALY) in patients or general population for various diseases. However, there has not been any systematic review summarizing the relationship between WTP per QALY and cost-effectiveness (CE) threshold based on World Health Organization (WHO) recommendation.

OBJECTIVE

To systematically review willingness-to-pay per quality-adjusted-life-year (WTP per QALY) literature, to compare WTP per QALY with Cost-effectiveness (CE) threshold recommended by WHO, and to determine potential influencing factors.

METHODS

We searched MEDLINE, EMBASE, Psyinfo, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Center of Research Dissemination (CRD), and EconLit from inception through 15 July 2014. To be included, studies have to estimate WTP per QALY in health-related issues using stated preference method. Two investigators independently reviewed each abstract, completed full-text reviews, and extracted information for included studies. We compared WTP per QALY to GDP per capita, analyzed, and summarized potential influencing factors.

RESULTS

Out of 3,914 articles founded, 14 studies were included. Most studies (92.85%) used contingent valuation method, while only one study used discrete choice experiments. Sample size varied from 104 to 21,896 persons. The ratio between WTP per QALY and GDP per capita varied widely from 0.05 to 5.40, depending on scenario outcomes (e.g., whether it extended/saved life or improved quality of life), severity of hypothetical scenarios, duration of scenario, and source of funding. The average ratio of WTP per QALY and GDP per capita for extending life or saving life (2.03) was significantly higher than the average for improving quality of life (0.59) with the mean difference of 1.43 (95% CI, 1.81 to 1.06).

CONCLUSION

This systematic review provides an overview summary of all studies estimating WTP per QALY studies. The variation of ratio of WTP per QALY and GDP per capita depended on several factors may prompt discussions on the CE threshold policy. Our research work provides a foundation for defining future direction of decision criteria for an evidence-informed decision making system.