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

KCE reports 100 ICER Thresholds 57
• A fixed ICER threshold value is incompatible with a fixed health care
budget. A fixed budget requires the revision of the ICER threshold value
every time a positive reimbursement decision is taken.
• In a flexible budget context, the ICER threshold value can be defined as
the maximum societal willingness to pay for a QALY (or LYG). At first
sight this approach looks appealing because it seems to take social values
better into account. The implementation of this approach requires
however:
o that the societal willingness to pay for a generic QALY can be
measured. Measurement of societal WTP for a QALY (or LYG) is
methodologically impossible because the value of a QALY is always
context-dependent.
o that the societal WTP adequately reflects the value of the health care
sector relative to other sectors. The use of societal WTP for a QALY
(or LYG) as a fixed ICER threshold value will ultimately determine (the
expansion of) the health care budget. The maximum societal WTP for
a QALY will have to be revised regularly to make sure that the health
care budget keeps reflecting the relative societal value of the health
care sector.
Because of these requirements, no country uses the maximum societal WTP for a
(generic) QALY (or LYG) as an ICER threshold value.
Some researchers have tried to derive the societal WTP from past decisions. As
explained in the report, this is an invalid approach, as decisions are never made
independent from additional considerations (e.g. equity, valuing patient or intervention
characteristics).
Three approaches identified in literature suggest to forget about the ICER threshold
value and to focus on other variables: the ICER of interventions as such (in comparison
with ICERs of other interventions but without reference to an ICER threshold value),
the opportunity costs of interventions or the disaggregated outcomes of the economic
evaluation.
• The first approach argues that the ICER is to be compared to the ICER of
another intervention without reference to an ICER threshold value. The
in-between comparison of ICERs allows policy makers to draw
conclusions on the relative cost-effectiveness of interventions, but does
not give a yes or no answer to the question of whether the intervention
increases the health care sector’s efficiency. Neither does it allow policy
makers to draw conclusions about the intervention’s value for money, as
this requires the inclusion of other considerations, such as equity, in the
decision making process. The advantage of the approach is that it
contributes to ‘objectifying’ the economic efficiency element in the
decision making process.
• The opportunity cost approach states that ICERs are not the right vehicle
for making resource allocation decisions. It requires making explicit where
the resources for financing a new intervention in a fixed budget context
must come from. This may be difficult in practice, especially in systems
where decisions are typically taken within sub-budgets of the total health
care budget and transfers between sub-budgets are not necessarily
considered (as is the case in Belgium).
• The cost-consequences approach refers to the disentangling of economic
evaluations into concrete elements and (economic) outcomes, enabling an
explicit weighting of the separate elements in the decision making process.
A combination of the different approaches will probably offer better support to decision
makers to assess the economic efficiency of interventions. For example presenting the
ICER as well as the disaggregated results of an economic evaluation will allow future
research in the ICER value above which an intervention does never obtain a positive
decision (irrespective of their ‘score’ on other criteria) but below which a decision can
still be negative