Valeurs seuils pour le rapport coût-efficacité en soins de santé - KCE

KCE reports 100 ICER Thresholds 21
The Ministry of Health prepares the annual health care budget which is considered to
be fixed for that year. Health care is primarily financed from public resources obtained
through general taxation. As such, the health care budget competes with other spending
priorities as a consequence of which the health care budget cannot easily be exceeded. j
Beveridge systems are, overall, characterised by many public providers and relatively
few private providers. 60
A Bismarck system, as prevailing in Belgium, France and Germany, is a social security
based system where social insurance is comprehensive and mandatory. 59 Resources
available for social security spending come from social security contributions, mainly
from salaried employees. There is generally a strong influence of stakeholders. For
instance, reimbursement of health care procedures is often negotiated between health
care providers, insurers and government. There is a mixture of private and public
providers and the health care budget is considered somewhat more flexible. 60
In a private insurance system, health care is paid out of premiums paid to private
insurance companies. The obvious example of this system is the US, where this system
is combined with a few limited social care fallback systems such as Medicare and
Medicaid.
2.7.1 Fixed budget
The ICER threshold value approach as described in 2.5.2 is applicable in situations
where the health care budget is strictly fixed (while other conditions also apply, see
2.5.1).
A fixed health care budget requires a variable ICER threshold value. Under a fixed
budget constraint, an ICER threshold value (with an appropriate range around it
representing uncertainty) against which other ICERs should be compared to maximise
health outcomes can be defined at a specific moment in time. But the ICER threshold
value cannot be fixed over time in a fixed budget situation, It has to be revised every
48, 61
time a positive reimbursement decision about a new intervention is taken.
A flexible health care budget does allow the use of a fixed ICER threshold value to a
certain extent. The budget will then have to expand every time a new intervention with
a lower ICER than the threshold ICER value becomes available. 62-64 k However, the
meaning and hence the interpretation of the ICER threshold value would in that case be
completely different (see 2.8.1). It is then no longer the health-maximising threshold
criterion for a fixed budget.
As explained previously the health care budget is more fixed in an NHS (Beveridge)
system than in a social security (Bismarck) system. In the UK, for instance, the budget of
the NHS is mainly exogenously determined by Parliament. 61
It is a fixed budget that should cover most or all health care expenditures of the
citizens. l As a consequence, the cost of an intervention is equal to the resources needed
from the health care budget.
j In practice, the health care budget of a given year can be exceeded in a Beveridge system, for example if
in a specific year more prescription drugs are used than initially expected. This will, however, be more
difficult than in a Bismarck system where budgets are more often negotiated.
k Expansion of the budget every time the ICER of an intervention is lower than the ICER threshold value is
not tenable in any system, be it a fixed or flexible budget system. Hence, regular adaptation of the ICER
threshold value will always be necessary. In systems with more flexible budgets, the revision of the ICER
threshold value might be less frequent than in systems with less flexible budgets (e.g. once a year or every
two years, in the context of an evaluation of the health care package funded from public resources and
their budgetary consequences). But, the constant revision of the ICER threshold value still requires the
satisfaction of the basic (and problematic) assumptions of the ‘conventional’ ICER threshold value
approach: perfect divisibility of health programmes, constant returns to scale and making abstraction of
equity considerations across patient populations in case of unweighted QALYs (or LYG). It could be
argued that perfect divisibility of programmes and constant returns to scale are less important conditions
for the ICER threshold value approach, but this only applies to systems with flexible budgets.
l In practice, the health care budget of a given year can be exceeded in a Beveridge system, for example if
in a specific year more prescription drugs are used than initially expected, but this will be more difficult
than in a Bismarck system where budgets are much more negotiated.