Valeurs seuils pour le rapport coût-efficacité en soins de santé - KCE
Valeurs seuils pour le rapport coût-efficacité en soins de santé - KCE
Valeurs seuils pour le rapport coût-efficacité en soins de santé - KCE
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42 ICER Thresholds <strong>KCE</strong> Reports 100<br />
But they also pay att<strong>en</strong>tion to the ro<strong>le</strong> of advisory panels in the <strong>de</strong>finition of the<br />
re<strong>le</strong>vant criteria and their relative importance for priority setting, and in making<br />
recomm<strong>en</strong>dations for reallocating resources on the basis of MCDA results.<br />
Daniels (oft<strong>en</strong> in collaboration with Sabin) has ma<strong>de</strong> some ethical ref<strong>le</strong>ctions on the<br />
<strong>de</strong>cision making process within health care groun<strong>de</strong>d in <strong>de</strong>mocratic and social justice<br />
theory. The basic princip<strong>le</strong> in Daniels’ ref<strong>le</strong>ction 143-148 is that a fair process is nee<strong>de</strong>d to<br />
establish <strong>le</strong>gitimacy for critical resource allocation <strong>de</strong>cisions. This process, labe<strong>le</strong>d as<br />
“accountability for reasonab<strong>le</strong>ness”, is based on <strong>de</strong>liberative processes (or <strong>de</strong>mocracy)<br />
at differ<strong>en</strong>t <strong>de</strong>cision making <strong>le</strong>vels. It puts forward four conditions for fair rationing that<br />
would <strong>en</strong>ab<strong>le</strong> to break op<strong>en</strong> the black box of health care <strong>de</strong>cision making:<br />
• Publicity: <strong>de</strong>cisions and the rationa<strong>le</strong>s for <strong>de</strong>cisions must be accessib<strong>le</strong>.<br />
This princip<strong>le</strong> implies that careful consi<strong>de</strong>ration should be giv<strong>en</strong> by<br />
<strong>de</strong>cision makers to the argum<strong>en</strong>ts for the choices they make. Publicity<br />
would <strong>le</strong>ad to transpar<strong>en</strong>cy and coher<strong>en</strong>ce in the giving of reasons.<br />
• Re<strong>le</strong>vance: The grounds for <strong>de</strong>cisions must be ones that peop<strong>le</strong>, who seek<br />
to cooperate with others on terms that are mutually justifiab<strong>le</strong>, can accept<br />
as re<strong>le</strong>vant to meet citiz<strong>en</strong>s or pati<strong>en</strong>ts needs fairly un<strong>de</strong>r resource<br />
constraints. This is particularly re<strong>le</strong>vant wh<strong>en</strong> claims are ma<strong>de</strong> that<br />
treatm<strong>en</strong>ts or technologies “cost too much” to be reimbursed, especially<br />
in situations where information is lacking to make these claims. In such<br />
cases it is of particular importance for the “<strong>le</strong>gitimacy” of the <strong>de</strong>mocratic<br />
process to be explicit about the procedures to take <strong>de</strong>cisions and <strong>de</strong>velop<br />
argum<strong>en</strong>ts un<strong>de</strong>rlying the (moral) reasons to take <strong>de</strong>cisions. Decision<br />
makers should be ma<strong>de</strong> “accountab<strong>le</strong> for the reasonab<strong>le</strong>ness”.<br />
• Appeals: there must be mechanisms to chal<strong>le</strong>nge and resolve limit-setting<br />
<strong>de</strong>cisions to revise and improve policies in the light of new evid<strong>en</strong>ce or<br />
argum<strong>en</strong>t.<br />
• Regulation: there must be some form of regulation to <strong>en</strong>sure that the<br />
previous conditions are met. These regulations could come through<br />
governm<strong>en</strong>tal regulation or through voluntary auto-regulation (but<br />
Daniels p<strong>le</strong>ads for an accreditation of this latter governance mo<strong>de</strong>l)<br />
Elaborating further on the notion of accountability for reasonab<strong>le</strong>ness, Gruskin and<br />
Daniels (2008) propose a human rights approach. 149 A human rights approach sets out a<br />
process that requires analyzing which rights and which populations would be positively<br />
or negatively affected by each interv<strong>en</strong>tion. Specific att<strong>en</strong>tion must be paid to who<br />
would b<strong>en</strong>efit most, and in what ways, from each interv<strong>en</strong>tion, and who would be <strong>le</strong>ft<br />
out.<br />
Key points<br />
• In real world <strong>de</strong>cision making, economic evaluations alone are not<br />
suffici<strong>en</strong>t to inform policy makers.<br />
• Neither theory nor empirical evid<strong>en</strong>ce supports the expectation that<br />
ICER threshold values will evolve as the so<strong>le</strong> <strong>de</strong>cision criterion. CEA<br />
findings should be used as inputs in a <strong>de</strong>liberative evid<strong>en</strong>ce based <strong>de</strong>cision<br />
making process that consi<strong>de</strong>rs the viewpoints and values of multip<strong>le</strong><br />
stakehol<strong>de</strong>rs.<br />
• Ensuring ‘accountability for reasonab<strong>le</strong>ness’ requires op<strong>en</strong>ing the black<br />
box of health care <strong>de</strong>cision making. Four conditions contribute to the<br />
‘accountability for reasonab<strong>le</strong>ness’: publicity, re<strong>le</strong>vance, appeals and<br />
regulation.