Willingness to Pay for Health-Related Quality of Life Gains in Relation to Disease Severity and the Age of Patients

Challenges in Value Assessment for One-Time Gene Therapies for Inherited Retinal Diseases: Are We Turning a Blind Eye?

OBJECTIVES

X-linked retinitis pigmentosa (XLRP) is a rare inherited retinal disease with no available treatment. Gene therapies in clinical trials will pose challenges for health technology assessment (HTA) if found to be safe and effective. We evaluated 2 of these challenges, namely acceptability and difficulties in assessing value beyond short-term patient health and healthcare savings and discounting in economic evaluation.

METHODS

We conducted a narrative literature review on the socioeconomic burden of XLRP to identify relevant components of value for a hypothetical gene therapy from a societal perspective and to assess their relative importance. We compared the resulting value profile against the value frameworks of three European HTA agencies. We also reviewed their guidelines on discounting and potential discounting issues specific to XLRP.

RESULTS

Much of the societal value of an XLRP gene therapy is likely to originate from productivity effects, carer spillovers, and value elements related to patient uncertainty. The evidence on these effects, however, is often limited, making it difficult for HTA agencies to assess them. Cost-effectiveness results are likely to be highly sensitive to the discount rate, and discounting will compound the effects of omitting important sources of value.

CONCLUSIONS

We have identified and detailed important components of societal value, key evidence gaps, and potential discounting issues for an XLRP gene therapy, which can inform future value assessments. Many of these may apply to gene therapies in other disease areas. Revisiting existing HTA approaches is recommended to ensure these are fit for purpose for such new classes of treatment.

Will the Institute for Clinical and Economic Review's Shared Savings Approach Decrease Value-Based Prices Most for the Most Severe Diseases?

OBJECTIVES

To identify the types of disease most likely to be affected by the Institute for Clinical and Economic Review's (ICER) shared savings assumptions.

METHODS

For diseases with treatments that were Food and Drug Administration approved between 2019 and 2023, annual direct and indirect economic burden and characteristics of each disease were extracted from peer-reviewed literature. ICER's shared savings methodology was applied 2 ways: 50/50 shared savings and $150 000 cost-offset cap. The primary outcome was the difference in eligible cost savings provided by a hypothetical disease cure under ICER's 2 shared savings methods. Characteristics of diseases most impacted by these 2 methods were evaluated descriptively.

RESULTS

Food and Drug Administration approved 260 therapies for 89 unique diseases between 2019 and 2023. Shared savings reduced value of a hypothetical cure for hemophilia A most (50/50 method: -$367 670 per year; cap method: -$585 340 per year), followed by acute hepatic porphyria (50/50 method: -$333 948; cap method: -$517 896) and paroxysmal nocturnal hemoglobinuria (50/50 method: -$291 997; cap method: -$433 993). Compared with diseases with annual burdens <$150 000, those ≥$150 000 had earlier disease onset by 22.0 years (age 12.3 vs 34.3), lower life expectancy by 10.6 years (55.8 vs 66.4 years), and lower disease prevalence (4.7 vs 1981.5 per 100 000). Shared savings' impact on health-benefit price benchmarks was projected to be larger for diseases with shorter life expectancy (ρ = -0.319; p =.005), worse quality of life (ρ = -0.263; P =.020), and lower prevalence (ρ = -0.418; P < .001).

CONCLUSIONS

ICER's shared savings assumptions would most likely have the largest negative impact on health-benefit price benchmarks for rare, severe, and pediatric diseases.

Early rituximab versus escalating therapy in neuromyelitis optica: A cost and quality of life analysis

INTRODUCTION

Rituximab, an anti-CD20 monoclonal antibody, has shown effectiveness in reducing disease relapses and disability accrual through relapses in patients with neuromyelitis optica spectrum disorders (NMOSD). However, its higher cost compared to oral immunosuppressants raises questions about its cost-effectiveness, particularly in low and middle-income countries. This study aimed to compare the cost-effectiveness of early rituximab treatment versus escalation treatment in NMOSD patients.

METHODS

We conducted a retrospective study of NMOSD patients treated with rituximab in the first five years of disease at a hospital in São Paulo, Brazil, from 2015 to 2019. The Early Group consisted of NMOSD patients who received rituximab as a first-line treatment. The Escalating Therapy Group included patients who were prescribed rituximab after experiencing disease activity while on oral immunosuppressants, primarily azathioprine. An economic model based on Expanded Disability Status Score (EDSS) transitions was used to assess cost-effectiveness. Cost and utility data were derived from previous studies, and sensitivity analyses for different willingness to pay (WTP) thresholds and percentage of patients upscaling from oral immunossupressants to rituximab were performed.

RESULTS

Thirty NMOSD patients were included. In the Early Group, the proportion of patients reaching the highest EDSS states (6.5 or more) decreased over five years compared to baseline. In contrast, the Escalating Therapy Group experienced an increase in this proportion over the same period. Cost-effectiveness was achieved for willingness to pay (WTP) of €20-80,000 in our main analysis, sustained in our sensitivity analysis.

CONCLUSION

Early treatment with rituximab has the potential to lower healthcare costs and enhance quality of life for NMOSD patients, supporting its early prescription for preventive treatment.

A Comparative Analysis of International Drug Price Negotiation Frameworks: An Interview Study of Key Stakeholders

Policy Points Health care systems around the world rely on a range of methods to ensure the affordability of prescription drugs, including negotiating prices soon after drug approval and relying on formal clinical assessments that compare newly approved therapies with existing alternatives. The negotiation framework established under the Inflation Reduction Act is far more limited than other frameworks explored in this study. Adding elements from these frameworks could lead to more effective price negotiation in the United States.

CONTEXT

In 2022, Congress passed the Inflation Reduction Act, which allowed Medicare, for the first time, to begin negotiating the prices for certain high-cost brand-name prescription drugs. Many other industrialized countries negotiate drug prices, and we sought to compare and contrast key features of the negotiation process across several health systems. We focused, in particular, on the criteria for selecting drugs for price negotiation, procedures for negotiation, factors that influence negotiated prices, and how prices are implemented.

METHODS

We included four G7 countries in our analysis (Canada, France, Germany, and the United Kingdom [England]), two Benelux countries (Belgium and the Netherlands), and one Scandinavian country (Norway) with long-established frameworks for drug price negotiation. We also analyzed the Veterans Affairs Health System in the United States. For each system, we gathered relevant legislation, government publications, and guidelines to understand negotiation frameworks, and we reached out to key drug price negotiators in each system to conduct semistructured interviews. All interviews were recorded, transcribed, and coded, and data were analyzed based on an internal assessment tool that we developed.

FINDINGS

All eight systems negotiate the prices of brand-name prescription drugs soon after approval and rely on formal clinical assessments that compare newly approved drugs with existing therapies. Systems in our study differed on characteristics such as whether the body performing clinical assessments is separate from the negotiating authority, how added health benefit is assessed, whether explicit willingness-to-pay thresholds are employed, and how specific approaches for priority disease areas are taken.

CONCLUSIONS

High-income countries around the world adopt different approaches to conducting price negotiations on brand-name drugs but coalesce around a set of practices that will largely be absent from the current Medicare negotiation framework. US policymakers might consider adding some of these characteristics in the future to improve negotiation outcomes.

Societal Preferences for Subsidizing Treatments Targeting Patients With Advanced Illness: A Discrete Choice Experiment

OBJECTIVES

Cost-effectiveness analyses are increasingly used to inform subvention decisions for moderately life extending treatments but apply several simplifying assumptions that may be inconsistent with public preferences. Contrary to standard assumptions, we hypothesize that societal willingness to allocate public funding toward these treatments is (1) diminishing for incremental improvements in survival and quality of life (QoL) and (2) greater for subvention policies that exclude the oldest old (>80 years).

METHODS

We tested these hypotheses using a web-based discrete choice experiment (n = 425) in Singapore. In each of 5 questions, respondents were shown 2 hypothetical treatments targeting patients with an expected prognosis of 2 months at very poor QoL and asked which treatment they wanted the government to subsidize, if any. Treatments were defined by 4 attributes: cost to the government, age of beneficiaries, expected gain in survival (2-12 months), and QoL (poor, fair, and good).

RESULTS

Latent class models were used to analyze results. Results revealed 2 classes. In the majority class (69.7% of sample), respondents value incremental gains in survival and QoL at a diminishing rate. Their willingness to allocate public funding estimates (Singapore dollars 16 825-91 027 per patient per month) were much higher than traditional cost-effectiveness thresholds. In the second class, respondents were unwilling to subsidize treatments offering less than 2 months of life extension or poor QoL. Neither class preferred subvention policies that exclude the oldest old.

CONCLUSIONS

These findings suggest that the Singapore government should consider cost-effectiveness thresholds that rise with increases in life extension. Age-based restrictions should not be imposed.

Examining the Effect of Depicting a Patient Affected by a Negative Reimbursement Decision in Healthcare on Public Disagreement with the Decision

BACKGROUND

The availability of increasingly advanced and expensive new health technologies puts considerable pressure on publicly financed healthcare systems. Decisions to not-or no longer-reimburse a health technology from public funding may become inevitable. Nonetheless, policymakers are often pressured to amend or revoke negative reimbursement decisions due to the public disagreement that typically follows such decisions. Public disagreement may be reinforced by the publication of pictures of individual patients in the media. Our aim was to assess the effect of depicting a patient affected by a negative reimbursement decision on public disagreement with the decision.

METHODS

We conducted a discrete choice experiment in a representative sample of the public (n = 1008) in the Netherlands and assessed the likelihood of respondents' disagreement with policymakers' decision to not reimburse a new pharmaceutical for one of two patient groups. We presented a picture of one of the patients affected by the decision for one patient group and "no picture available" for the other group. The groups were described on the basis of patients' age, health-related quality of life (HRQOL) and life expectancy (LE) before treatment, and HRQOL and LE gains from treatment. We applied random-intercept logit regression models to analyze the data.

RESULTS

Our results indicate that respondents were more likely to disagree with the negative reimbursement decision when a picture of an affected patient was presented. Consistent with findings from other empirical studies, respondents were also more likely to disagree with the decision when patients were relatively young, had high levels of HRQOL and LE before treatment, and large LE gains from treatment.

CONCLUSIONS

This study provides evidence for the effect of depicting individual, affected patients on public disagreement with negative reimbursement decisions in healthcare. Policymakers would do well to be aware of this effect so that they can anticipate it and implement policies to mitigate associated risks.

Acne scars impact on the quality of life and the willingness to pay for treatments among adults in Riyadh, Saudi Arabia: A cross-sectional study

Objectives

Acne scarring occurs from skin damage following acne healing. Treatments such as chemical peels, dermabrasion, and laser therapy can effectively enhance scars' appearance but could be expensive. This study aimed to reflect participants' awareness of treatment options and their willingness to pay (WTP), evaluating their association with sociodemographics, severity, and quality of life (QoL).

Material and Methods

A cross-sectional study was conducted in Riyadh, Saudi Arabia, from June to July of 2023. Study participants were chosen using a non-probability sampling technique. Participants were aged 18 or older, had acne scarring, and resided in Riyadh. Data analysis was performed using RStudio, with P < 0.05 indicating statistical significance.

Results

A total of 401 adult participants were included in the study. The prevalence of acne scarring among the participants was 63.4%. About 45.8% of the participants expressed a WTP of <1000 Saudi Riyals (SAR), while 42.2% were willing to pay 1000-6000 SAR. The most well-recognized acne scar management modalities were laser resurfacing (66.3%) and chemical peels (64.1%), while the least recognized were collagen/fat filler injections (23.9%) and radiofrequency microneedling (27.7%).

Conclusion

The most recognized acne scar treatment modalities were laser resurfacing and chemical peels. Participants were willing to pay for reasons such as psychological impact, income levels, and awareness of treatment modalities. The findings could influence dermatologists to start awareness campaigns to debunk misconceptions about acne scar treatment modalities and their efficacy in improving QoL.

Cost-effectiveness and threshold analysis of deep brain stimulation vs. treatment-as-usual for treatment-resistant depression

Treatment-resistant depression (TRD) affects approximately 2.8 million people in the U.S. with estimated annual healthcare costs of $43.8 billion. Deep brain stimulation (DBS) is currently an investigational intervention for TRD. We used a decision-analytic model to compare cost-effectiveness of DBS to treatment-as-usual (TAU) for TRD. Because this therapy is not FDA approved or in common use, our goal was to establish an effectiveness threshold that trials would need to demonstrate for this therapy to be cost-effective. Remission and complication rates were determined from review of relevant studies. We used published utility scores to reflect quality of life after treatment. Medicare reimbursement rates and health economics data were used to approximate costs. We performed Monte Carlo (MC) simulations and probabilistic sensitivity analyses to estimate incremental cost-effectiveness ratios (ICER; USD/quality-adjusted life year [QALY]) at a 5-year time horizon. Cost-effectiveness was defined using willingness-to-pay (WTP) thresholds of $100,000/QALY and $50,000/QALY for moderate and definitive cost-effectiveness, respectively. We included 274 patients across 16 studies from 2009-2021 who underwent DBS for TRD and had ≥12 months follow-up in our model inputs. From a healthcare sector perspective, DBS using non-rechargeable devices (DBS-pc) would require 55% and 85% remission, while DBS using rechargeable devices (DBS-rc) would require 11% and 19% remission for moderate and definitive cost-effectiveness, respectively. From a societal perspective, DBS-pc would require 35% and 46% remission, while DBS-rc would require 8% and 10% remission for moderate and definitive cost-effectiveness, respectively. DBS-pc will unlikely be cost-effective at any time horizon without transformative improvements in battery longevity. If remission rates ≥8-19% are achieved, DBS-rc will likely be more cost-effective than TAU for TRD, with further increasing cost-effectiveness beyond 5 years.

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.

Understanding the National Institute for Health and Care Excellence Severity Premium: Exploring Its Implementation and the Implications for Decision Making and Patient Access

OBJECTIVES

This study aimed to evaluate the impact of the National Institute for Health and Care Excellence's (NICE) new severity modifier, which has replaced the end-of-life (EoL) premium, on future NICE recommendations, considering past decision-making patterns.

METHODS

NICE technology appraisals (TAs) published between January 2020 and December 2022 were reviewed. Summary statistics were generated to assess how the new severity modifier might affect hypothetical decision making in historical TAs.

RESULTS

A total of 138 data points were identified from 132 TAs. Although the EoL premium was applied in 46 appraisals (33%), 57 (39%) qualify for a severity-based quality-adjusted life-year (QALY) multiplier. Only 19 appraisals (14.6%) not receiving an EoL premium met the severity criteria, the majority (17) qualifying for a 1.2× multiplier. In appraisals predicted to meet the severity criteria, 45 (79%) were in oncology, making them 4.04 times (95% CI 1.91-9.02) more likely to qualify for a severity modifier than nononcology indications. Among historically EoL indications, 42 (91%) were predicted to meet the severity criteria, making them 14.8 times (95% CI 6.37-37.6) more likely to qualify for a severity modifier.

CONCLUSIONS

The new severity modifier will predominantly benefit oncology indications, continuing their previous explicit prioritization under the EoL decision modifier. However, the new severity modifier is harder to achieve and less generous; only a fraction of appraisals qualify for the highest effective £51 000 per QALY threshold. The vast majority of indications previously approved at £50 000 per QALY would now need to meet a cost-effectiveness threshold of <£36 000. This may necessitate greater pricing flexibility from manufacturers and increase the likelihood of negative recommendations.

A QALY is [still] a QALY is [still] a QALY? : Evaluating proportional shortfall as the answer to the problem of equity in healthcare allocations

Despite clinical evidence of drug superiority, therapeutic modalities, like combination immunotherapy, are mostly considered cost-ineffective due to their high costs per life year(s) gained. This paper, taking an ethical stand, reevaluates the standard cost-effectiveness analysis with that of the more recent justice-enhanced methods and concludes by pointing out the shortcomings of the current methodologies.

Systematic Review of the Relative Social Value of Child and Adult Health

OBJECTIVES

We aimed to synthesise knowledge on the relative social value of child and adult health.

METHODS

Quantitative and qualitative studies that evaluated the willingness of the public to prioritise treatments for children over adults were included. A search to September 2023 was undertaken. Completeness of reporting was assessed using a checklist derived from Johnston et al. Findings were tabulated by study type (matching/person trade-off, discrete choice experiment, willingness to pay, opinion survey or qualitative). Evidence in favour of children was considered in total, by length or quality of life, methodology and respondent characteristics.

RESULTS

Eighty-eight studies were included; willingness to pay (n = 9), matching/person trade-off (n = 12), discrete choice experiments (n = 29), opinion surveys (n = 22) and qualitative (n = 16), with one study simultaneously included as an opinion survey. From 88 studies, 81 results could be ascertained. Across all studies irrespective of method or other characteristics, 42 findings supported prioritising children, while 12 provided evidence favouring adults in preference to children. The remainder supported equal prioritisation or found diverse or unclear views. Of those studies considering prioritisation within the under 18 years of age group, nine findings favoured older children over younger children (including for life saving interventions), six favoured younger children and five found diverse views.

CONCLUSIONS

The balance of evidence suggests the general public favours prioritising children over adults, but this view was not found across all studies. There are research gaps in understanding the public's views on the value of health gains to very young children and the motivation behind the public's views on the value of child relative to adult health gains.

CLINICAL TRIAL REGISTRATION

The review is registered at PROSPERO number: CRD42021244593. There were two amendments to the protocol: (1) some additional search terms were added to the search strategy prior to screening to ensure coverage and (2) a more formal quality assessment was added to the process at the data extraction stage. This assessment had not been identified at the protocol writing stage.

Methodological challenges and potential solutions for economic evaluations of palliative and end-of-life care: A systematic review

BACKGROUND

Given the increasing demand for palliative and end-of-life care, along with the introduction of costly new treatments, there is a pressing need for robust evidence on value. However, comprehensive guidance is missing on methods for conducting economic evaluations in this field.

AIM

To identify and summarise existing information on methodological challenges and potential solutions/recommendations for economic evaluations of palliative and end-of-life care.

DESIGN

We conducted a systematic review of publications on methodological considerations for economic evaluations of adult palliative and end-of-life care as per our PROSPERO protocol CRD42020148160. Following initial searches, we conducted a two-stage screening process and quality appraisal. Information was thematically synthesised, coded, categorised into common themes and aligned with the items specified in the Consolidated Health Economic Evaluation Reporting Standards statement.

DATA SOURCES

The databases Medline, Embase, HTADatabase, NHSEED and grey literature were searched between 1 January 1999 and 5 June 2023.

RESULTS

Out of the initial 6502 studies, 81 were deemed eligible. Identified challenges could be grouped into nine themes: ambiguous and inaccurate patient identification, restricted generalisability due to poor geographic transferability of evidence, narrow costing perspective applied, difficulties defining comparators, consequences of applied time horizon, ambiguity in the selection of outcomes, challenged outcome measurement, non-standardised measurement and valuation of costs as well as challenges regarding a reliable preference-based outcome valuation.

CONCLUSION

Our review offers a comprehensive context-specific overview of methodological considerations for economic evaluations of palliative and end-of-life care. It also identifies the main knowledge gaps to help prioritise future methodological research specifically for this field.

Willingness to pay for cancer prevention versus treatment in China: implications for cost-effectiveness threshold

BACKGROUND

Empirical support for the appropriate cost-effectiveness threshold (CET) in China remains sparse.

OBJECTIVE

This study aimed to estimate the willingness to pay (WTP) for cancer prevention and treatment from the perspective of healthcare policy-makers (i.e. supply side) and to investigate whether there is a difference between the estimated WTP in two scenarios.

METHODS

We conducted a web-based survey from May to July 2022 among experts who offering consultation to the government. We surveyed 79 experts from a national think-tank (84.81% response rate) using contingent valuation method, a method for estimating the monetary value that individuals place on a non-market service.

RESULTS

The mean WTP for two scenarios were estimated at 1.29 times of per capita Gross Domestic Product (GDP) of China and 1.90 times of per capita GDP, respectively. There was a difference between the WTP in the two scenarios and the WTP for treatment was significantly higher than prevention.

CONCLUSION

The findings suggest that though there is a smaller gap between the two scenarios in China as compared to other countries, the WTP may vary under different scenarios. So there's a need to further refine the development of CET by adding parameters like prevention instead of defining one universal threshold.

Generic Health Utility Measures in Exercise Oncology: A Scoping Review and Future Directions

Despite the evidence that exercise is effective at mitigating common side effects in adults with cancer, it is rarely part of usual cancer care. One reason for this is the lack of economic evidence supporting the benefit of exercise. Economic evaluations often rely on the use of generic utility measures to assess cost effectiveness. This review identifies and synthesizes the literature on the use of generic utility measures used to evaluate exercise interventions for adults with cancer. A systematic search of the literature from January 2000 to February 2023 was conducted using four databases (Medline, EMBASE, CINAHL, Academic Search Complete). Exercise studies involving adults with any type of cancer that used a generic utility measure were eligible for inclusion. Of the 2780 citations retrieved, 10 articles were included in this review. Seven articles included economic evaluations, with varying results. Four studies reported on cost-effectiveness; however, detailed effectiveness data derived from the generic utility measure were often not reported. Generic utility measures help to compare baseline values of and changes in health utility weights across studies and to general population norms; however, to date, they are underutilized in exercise oncology studies. Consideration should be given to the identified research evidence, population, and methodological gaps.

10 Years of AMNOG: What is the Willingness-to-Pay for Pharmaceuticals in Germany?

OBJECTIVES

The German Pharmaceutical Market Restructuring Act (AMNOG, 2011) is a two-stage process to regulate the price of new pharmaceuticals in which price negotiations are conducted based on evidence-based medical benefit assessments using data from prior clinical trials. Although the act does not explicitly set a willingness-to-pay (WTP) threshold, the process itself implicitly establishes a WTP for health improvement. We evaluated the implicit WTP for prescription pharmaceuticals post-AMNOG in the German healthcare system from the decision-maker/payer perspective.

METHODS

We extracted data on patient-group-specific annual treatment costs and endpoints from 2011 to 2021 from the dossiers assessed by the German Federal Joint Committee (FJC; Gemeinsamer Bundesausschuss). Using incremental cost-effectiveness ratios (ICERs), we calculated a WTP for the indications (I) diabetes, (II) cardiovascular disease, and (III) psoriasis weighted according to patient group size, first from the perspective of the decision-maker (approach A), and second from the perspective of the industry (approach B). To put clinical outcome measures into relation to one another, minimum clinically important differences (MCIDs) were derived from the literature and compared.

RESULTS

The annual treatment costs of newly authorized drugs were substantially higher (both pre- and post-negotiation) than that of their comparators (e.g., psoriasis, pre-negotiation: €20,601.59, post-negotiation: €16,763.57; comparators: €5178.00). However, although newly launched drugs were more expensive than their comparators, they brought greater medical benefits and were more aligned with value (r = 0.59, P < 0.001) than older drugs. We estimated WTP to vary widely by indication group [€33,814.08 per 1 percentage point hemoglobin A1c (HbA1c) reduction for diabetes, €10,970.83 per life year gained for cardiovascular disease, and €663.46 per 1% PASI decrease for psoriasis; approach A]. WTP was converted to MCID thresholds: diabetes: €16,907.04; cardiovascular drugs: no MCID existent to convert; and psoriasis: €33,173.00. WTP remained constant over time for diabetes and cardiovascular drugs but increased for psoriasis drugs.

CONCLUSION

This paper is one of the first to estimate the implicit WTP for prescription pharmaceuticals post-AMNOG and suggests that the WTP may vary between different therapeutic areas. Additionally, making different assumptions (approach A versus approach B) with regard to the assumed effectiveness in indication areas that had been declared as having no additional benefit by the FJC may explain the different perspectives of decision-makers and of the pharmaceutical industry on the value of a pharmaceutical.

Eliciting Trade-Offs Between Equity and Efficiency: A Methodological Scoping Review

OBJECTIVES

To identify differences in the approaches and results of studies that elicit equity-efficiency trade-offs that can inform equity-informative cost-effectiveness analysis for healthcare resource allocation.

METHODS

We searched Ovid (Medline), EconLit, and Scopus prior to June 25, 2021. Inclusion criteria were: (1) peer-reviewed or (2) gray literature; (3) published in English; (4) survey-based; (5) parameterized a social welfare function to quantify inequality aversion or (6) elicited a trade-off in equity and efficiency characteristics of health interventions. Exclusion criteria were: (1) studies that did not conduct a trade-off or (2) theoretical studies. We abstracted details on study methods, results, and limitations. Studies were grouped by following approach: (1) social welfare function or (2) preference ranking and distributional weighting. We described findings separately for each approach category.

RESULTS

Seventy-seven papers were included, 28 parameterized social welfare functions and 49 were classified as preference ranking and distributional weighting. Study methods were heterogeneous. Studies were conducted across 29 countries. Sample sizes and composition, survey methods and question framing varied. Preferences for equity were mixed. Across both approach categories: 39 studies were classified as clear evidence of inequality aversion; 33 found mixed evidence; and 4 had no evidence of aversion. Evidence of between and within-study heterogeneity was found. Preferences for equity may differ by gender, profession, political ideology, income, and education.

CONCLUSIONS

Substantial variability in study methods limit the direct comparability of findings and their use in equity-informed cost-effectiveness analysis. Future researches using representative samples that explore within and between country heterogeneity is needed.

The Value of Health in a Cost-Effectiveness Analysis: Theory Versus Practice

A cost-effectiveness analysis has become an important method to inform allocation decisions and reimbursement of new technologies in healthcare. A cost-effectiveness analysis requires a threshold to which the cost effectiveness of a new intervention can be compared. In principle, the threshold ought to reflect opportunity costs of reimbursing a new technology. In this paper, we contrast the practical use of this threshold within a CEA with its theoretical underpinnings. We argue that several assumptions behind the theoretical models underlying this threshold are violated in practice. This implies that a simple application of the decision rules of CEA using a single estimate of the threshold does not necessarily improve population health or societal welfare. Conceptual differences regarding the interpretation of the threshold, widely varying estimates of its value, and an inconsistent use within and outside the healthcare sector are important challenges in informing policy makers on optimal reimbursement decision and setting appropriate healthcare budgets.

Preferences for investment in and allocation of additional healthcare capacity

Policy makers need to make decisions regarding the allocation of scarce healthcare resources. We study preferences for investment in additional healthcare capacity and allocation between two regions, focusing on reducing waiting time for elective surgery for a physical health problem. We elicit preferences from a societal and an individual perspective, with unequal initial waiting times between the two regions. In an online survey, 1039 respondents were randomly assigned to one of three versions of the experiment: (1) a social planner perspective, placing respondents in the role of a policy maker; (2) an individual perspective where the respondent's own region was better off regarding initial waiting times; (3) an individual perspective where the individual's own region was worse off regarding initial waiting times. Respondents were asked to rank the status quo and five scenarios where the investment in additional capacity led to different distributions of shorter waiting times between regions. For all allocations we presented both the reduction in waiting time and the resulting final waiting time for both regions. We find that in version 1 of the experiment, preferences were in line with inequality aversion and Rawlsian preferences regarding final waiting time. In version 3, similar preferences were found, although here they also align with individualistic preferences. In version 2, preferences were more heterogeneous, with both individualistic and egalitarian preferences present. Concluding, individualistic and egalitarian preferences mostly concerned final waiting time. We therefore recommend policy makers to focus on the effect on final waiting time instead of the reduction of waiting time.

Reference-dependent age weighting of quality-adjusted life years

People do not only care about maximizing health gains but also about their distribution. For example, they give more weight to younger patients than older patients. This pilot study aims to investigate if age weighting is reinforced by loss aversion if young people are falling behind one's perceived 'normal' quality of life (QoL), while older people do not. We apply a person trade-off method in a large representative sample (n = 990) to estimate age weighting factors. We also measure QoL levels that individuals regard as 'normal' for different ages, serving as reference points. We observe a considerable amount of age weighting, with 20-year-old patients on average receiving 1.7 times as much weight as 80-year-old patients. Perceived 'normal' QoL rapidly decreases with age of a patient. Older people are more optimistic about what constitutes 'normal QoL' than younger people, but they express a faster decline in normal QoL due to aging. Respondents who view all improvements to be gain enlarging show the least age weighting, but loss aversion cannot explain the results. Still, one's age-related reference level is an important predictor of age weights. Given the explorative nature of this study, further studies are called for to generate more robust evidence.

Valuing treatment in oncology: embracing a broader notion of value

Over the past decade, we have witnessed unprecedented, groundbreaking innovation in pharmaceuticals. This has been particularly true in oncology, where new therapies have increased survival and at times offered clinical cure. However, the impact of these promising treatments has been attenuated by persistent access and cost challenges that may limit their effect. A narrative has emerged that many of these so-called breakthroughs are not priced according to the value they provide. Traditional cost-effectiveness analyses would appear to support these doubts, often suggesting that innovative therapies do not represent value for money. However, there is a case to be made that innovative therapies require equally innovative value assessments. To explore this emerging viewpoint, this article provides a brief introduction to the current value debate and oncology-specific considerations when assessing elements of value. We offer a brief background on the nature and development of quality-adjusted life-years as a part of cost-effectiveness analyses and some of their key limitations; a primer on "novel" elements of value, which capture specific aspects of patient and societal preferences not included in quality-adjusted life-years; and their applicability to oncology including discussion on areas where further thought and research might be needed. We conclude with a potential checklist of novel elements of value that should be considered. DISCLOSURES: This Viewpoints article was funded by Novartis, Inc., which also provided funding to COVIA Health Solutions for manuscript development. The sponsor was involved in developing the manuscript. Kamal-Bahl and Puckett are employees of COVIA Health Solutions, a consulting firm that provides services to biopharmaceutical clients, trade organizations, and foundations. Kamal-Bahl holds stock in Merck and Pfizer. Singh is an employee of Novartis Pharmaceuticals. Willke received personal fees from COVIA Health Solutions for work on the manuscript.

The ‘Red Herring’ Hypothesis: Some Theory and New Evidence

The ‘red herring’ hypothesis (RHH) claims that apart from income and medical technology, proximity to death rather than age constitutes the main determinant of healthcare expenditure (HCE). This paper seeks to underpin the RHH with some theory to derive new predictions also for a rationed setting, and to test them against published empirical evidence. One set comprising ten predictions uses women’s longer life expectancy as an indicator of the difference in time to death in their favor. Out of 28 testing opportunities drawn from the published evidence, in the case of no rationing seven out of eleven result in full and two in partial confirmation; in the case of rationing, twelve out of 17 result in full and one in partial confirmation. The other set, containing 35 testing opportunities, concerns the age profile of HCE. In the case of no rationing, seven out of twelve result in full and four in partial confirmation; in the case of rationing, eleven out of 23 in full and nine in partial confirmation. There are but ten contradictions in total. Overall, the new tests of the RHH can be said to receive a good deal of empirical support, both from countries and settings with and without rationing.

Willingness to pay for quality and length of life gains in end of life patients of different ages

Health gains are increasingly weighted in economic evaluations of new health technologies to guide resource-allocation decisions in healthcare. In Norway and the Netherlands weights are, for example, based on the disease severity of patients. In England and Wales, a higher weight is attached to quality-adjusted life-years (QALYs) gained from life-extending end-of-life (EOL) treatments. Societal preferences for QALY gains in EOL patients are increasingly examined. Although the available evidence suggests that gains in health-related quality of life (QOL) may be preferred to gains in life expectancy (LE), little is known about the influence of EOL patients' age on these preferences. In this study, we examine the willingness to pay (WTP) for QOL and LE gains in EOL patients of different ages in a sample (n = 803) of the general public in the Netherlands. We found that WTP was relatively higher for QOL and LE gains in younger EOL patients. We further found indications suggesting that WTP may be relatively higher for QOL gains at the EOL, except for patients aged 20 for whom we observed a higher WTP for LE gains. Our results may inform discussions on attaching differential weights to QOL and LE gains in EOL patients of different ages with the objective to better align resource-allocation decisions with societal preferences.