Deviation from opportunity cost on any ground, including that 'justified' by innovation (and maybe severity and uncertainty), undermines the ethical justification for cost-effectiveness analysis. So the same case for separate funding should apply, rather than threshold manipulation, shoudn't it?
If we truly value outcomes more highly for those with more severe conditions, or we are risk averse and value more highly treatments for rare (but debilitating) conditions, is that a deviation from opportunity cost?
The ethical justification for CE in a resource constrained public heakth service lies is the use of a generic outcome measure (GOM) which treats every individual equally. Severity SHOULD be captured in the GOM, rarity not (innovativeness etc certainly not). My direction of travel is to a single unmodifiable threshold with separate funding decisions/pots (as you suggest) for all things we value for reasons beyond CE measured generically
I have pursued my direction of travel further Andy. (I look forward to the February 11 discussion at LSHTM but don’t want to hide behind the Chatham House rule in operation there.).
The ethical bias of cost-effectiveness as an allocation criterion in the healthcare commons resides in its equitable treatment of every individual citizen. NICE should therefore operate on a single ICER (TBD) across all interventions, without adjustment of any sort.
If there are problems with the existing QALY measure, such as missing dimensions or levels of severity, these should be addressed directly, not by messing around with the threshold in a conceptually and ethically unjustifiable way. (This may require Eq-5d-5l to be replaced by, say, EQ-9D-13L)
There may still be a legitimate political desire to fund beyond what emerges from this corrected equitable measure as cost-effective, for instance on the basis of considerations such as rarity (as distinct from severity), social disadvantage, or innovativeness, or … But this should come from a separate, explicitly political, pot, definitely not NICE-administered (as a hot potato depository with too much medical/’scientific’ input into non-medical/’scientific’ issues)
Another interesting piece! A query: NIHCE also evaluates non-pharmaceutical interventions. Decision-making around these kinds of interventions may be less prone to manipulation for economic policy reasons but is there a case for a Public Health Fund also?
I'm imagining a situation where we have a pharmaceutical fund and a Public Health fund and we allow the size of the fund to determine the threshold (shadow price) implied. Comparing the thresholds between the two funds would show just how much value the Government is placing on Public Health versus supporting the Life Sciences sector? At the very least could shine a light on the implications of funding decisions?
Deviation from opportunity cost on any ground, including that 'justified' by innovation (and maybe severity and uncertainty), undermines the ethical justification for cost-effectiveness analysis. So the same case for separate funding should apply, rather than threshold manipulation, shoudn't it?
If we truly value outcomes more highly for those with more severe conditions, or we are risk averse and value more highly treatments for rare (but debilitating) conditions, is that a deviation from opportunity cost?
The ethical justification for CE in a resource constrained public heakth service lies is the use of a generic outcome measure (GOM) which treats every individual equally. Severity SHOULD be captured in the GOM, rarity not (innovativeness etc certainly not). My direction of travel is to a single unmodifiable threshold with separate funding decisions/pots (as you suggest) for all things we value for reasons beyond CE measured generically
I have pursued my direction of travel further Andy. (I look forward to the February 11 discussion at LSHTM but don’t want to hide behind the Chatham House rule in operation there.).
The ethical bias of cost-effectiveness as an allocation criterion in the healthcare commons resides in its equitable treatment of every individual citizen. NICE should therefore operate on a single ICER (TBD) across all interventions, without adjustment of any sort.
If there are problems with the existing QALY measure, such as missing dimensions or levels of severity, these should be addressed directly, not by messing around with the threshold in a conceptually and ethically unjustifiable way. (This may require Eq-5d-5l to be replaced by, say, EQ-9D-13L)
There may still be a legitimate political desire to fund beyond what emerges from this corrected equitable measure as cost-effective, for instance on the basis of considerations such as rarity (as distinct from severity), social disadvantage, or innovativeness, or … But this should come from a separate, explicitly political, pot, definitely not NICE-administered (as a hot potato depository with too much medical/’scientific’ input into non-medical/’scientific’ issues)
.
Another interesting piece! A query: NIHCE also evaluates non-pharmaceutical interventions. Decision-making around these kinds of interventions may be less prone to manipulation for economic policy reasons but is there a case for a Public Health Fund also?
I'm imagining a situation where we have a pharmaceutical fund and a Public Health fund and we allow the size of the fund to determine the threshold (shadow price) implied. Comparing the thresholds between the two funds would show just how much value the Government is placing on Public Health versus supporting the Life Sciences sector? At the very least could shine a light on the implications of funding decisions?