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

KCE reports 100 ICER Thresholds 33
The entire GDP might not even be enough if citizens require combinations of
treatments whose total average cost-per-QALY exceeds the average GDP per capita.
Therefore, this approach is not feasible and conflicts with the efficiency evaluation
objective of economic evaluation.
2.8.5 The opportunity costs approach
Gafni and Birch have argued that CEA and ICERs may not be very useful in real life
decision making contexts, even for maximizing health from a given budget, simply
because the basic conditions for using ICERs for this purpose are not and can never be
fulfilled. 50, 68 Either ICERs would be interpreted as in the theoretical ICER threshold
value approach, which is inappropriate given that the baseline conditions are not fulfilled
(see 2.7). Or, alternatively, the ICER threshold value would be defined as a value for the
societal WTP per QALY (or LYG), in which case the threshold approach would
inevitably lead to budget expansions. 98 There is evidence from Ontario (Canada),
England and Australia that the adoption of the ICER threshold value approach has
indeed been associated with substantial unplanned increases in healthcare expenditures
62, 64
without any evidence of any increase in total health benefit.
The suggested alternative to the use of ICERs and CEA in a decision making context
characterized by fixed budgets is to present the real opportunity costs of the
implementation of the programme under consideration. 63, 98 The opportunity costs of
the programme are equal to the health benefits foregone in other programmes that
have to be downgraded or abolished to finance the new one. It implies the notion of
choice between desirable but mutually exclusive outcomes. If the benefits foregone
from the cancelled programme are higher than the benefits generated by the new
programme, the new programme should not be funded from the limited budget (unless
there are other non health-economic arguments to fund it).
As such, the additional resource requirements are identified and the implications of
cancelling other interventions are made explicit. 46 This increases the transparency of the
decision making process.
The implementation of this approach on a national level might be problematic for
different reasons. It is difficult to know precisely which activities will be displaced to be
able to implement a new intervention. As a result, only accepting new technologies if
the source of the resources is made explicit could paralyse the system. Other decision
problems might appear. For example, what happens if in a decentralised reimbursement
decision system decision makers think to find the resources for two different
interventions from disinvestment in the same third intervention? Furthermore,
interventions with a large budget impact will probably be more problematic to
implement than projects with a smaller budget impact, even if they may be more costeffective,
since they will need to identify relatively more projects to sacrifice.
On a local or institutional level, their may be more possibilities to use the opportunity
cost approach. For example, hospitals that have to decide on buying a new device or
implementing a new health care programme, might consider the savings they will have
to realize elsewhere in their organization to free resources for the new investments.
Despite the potential practical problems, the opportunity cost approach makes the
important point that disinvestments are always needed in a system with a fixed budget.
First candidates for disinvestment should be interventions that have become obsolete
or are no longer considered worth their costs. In a mixed public-private financing
system, the opportunity cost approach might become even more complex, because
every decision to reduce public financing of an intervention (in order to contain costs
from the perspective of the public payer) has a potential impact on both health and
income inequalities.