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

58 ICER Thresholds KCE Reports 100
(= an implied ICER threshold, reflecting the absolute maximum society is willing to pay
for an additional QALY or LYG). It will moreover familiarize policy makers with the
ICER even if they do not wish to give a high weight to the ICER in decisions about
specific technologies. This will eventually lead to a reference set in the minds of health
care policy makers, against which they can value the ICER of new interventions. This is
obviously a long-term and gradual process.
4.3 HEALTH CARE DECISION MAKING CONTEXTS
This report also briefly discussed the use of economic evaluations in health care
decision making. The most important insight from this overview is that decision making
processes cannot be reduced to a purely technocratic and rational assessment. From a
social justice perspective on decision making, there are good arguments to pursue to
clarify on and make the argumentative logic more transparent. More reflection and
rationality in health care decision making is certainly worth pursuing. The principle that
decisions should be substantiated with well documented, transparently brought scientific
and other knowledge is increasingly accepted.
Health technology assessment is becoming a very useful methodology to support this
ambition. Economic evaluation is part of any HTA and neglecting economic arguments
would be unethical. As resources cannot be consumed twice, choices are inevitable.
Consuming health care resources for one intervention implies denying these resources
to another intervention. And precisely these choices need deliberation. Besides
economic and clinical research based arguments, social justice considerations remain a
core element in the decision making process. The question on the allocation of limited
resources to obtain optimal outcomes is therefore not a technical “neutral” issue but
also an issue of societal values. These values develop within political, social and
economic contexts. The economic efficiency argument will weigh differently in decision
making processes. Economic (technical rational) criteria will be given another meaning
e.g. according to the health care field (e.g. preventive, curative, long term care, end-of
life care) or the population addressed with the intervention (e.g. children). This is one
of the reasons why decision makers should not solely rely on seemingly simple tools
such as ICERs and ICER threshold values. In order to make more optimal use of
economic analyses in health care decision making, researchers and analysts should
become more aware that decisions on the use of health interventions are likely to be
influenced by a range of social, financial and institutional factors. Taking better into
account this knowledge would bring us closer to the core aims of HTA.
4.4 SUGGESTIONS FOR FURTHER RESEARCH
We need more research on the appropriateness of the theoretical foundations of the
ICER and ICER threshold value for different health care systems. In particular, the
difference between social security-based systems and NHS-based systems is relevant for
at least two reasons: on the one hand the budgetary context (fixed or flexible), on the
other hand the characteristics of the decision making processes. The literature
currently relies on the assumption of a universally applicable theory of CEA, but
arguments can be made in favour of a more context-sensitive analysis:
• First, much of the literature on ICERs and ICER threshold values implicitly
assumes a Beveridge-type health care model or -if not- simply ignores the
specificities of the health care system. Health care systems do for instance
not all operate within a fixed budget approach (e.g. we argued why a fixed
ICER threshold value is incompatible with a fixed budget (a NHS-based
system) and why it would be more, yet not completely, compatible with a
social security system). We need further theoretical and methodological
elaboration of CEA taking the health care system characteristics into
account.