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

60 ICER Thresholds KCE Reports 100
5 CONCLUSION
The aim of this report is to provide a reference document for non-health economists
on economic evaluation in health care, its basic concepts and its potential value for
health care policy making. The report explains why ICER threshold values, defined in
their neo-classical welfarist sense and under a fixed budget constraint, have a theoretical
basis that is, however, untenable in daily practice because basic assumptions are not
fulfilled. This raises the question about whether we still need ICERs, since, according to
theory, they should be compared with an ICER threshold value.
ICERs can be valuable in two ways:
• define the ICER threshold value as the maximum societal WTP for a unit
of health effect. This option requires a flexible budget and the
measurement of the maximum societal WTP for a generic QALY.
• determine the acceptability of an ICER on a case-by-case basis by
evaluating the societal WTP for a unit of health effect for each
intervention separately. This option does not require the identification of
an ICER threshold value but derives interventions’ relative costeffectiveness
by means of in-between comparisons of ICERs. Other
considerations are weighed against the efficiency criteria once the relative
position of the intervention’s ICER compared to other interventions’
ICERs is determined.
Other options, not using the ICER, to inform health policy makers about the efficiency
of interventions are:
• the opportunity cost approach
• the cost-consequences approach.
Clearly, each of these approaches has its merits and weaknesses. The budgetary context
is an important determinant for the applicability of the alternatives but also
methodological issues may impede the application of an approach. Because it is unethical
to ignore economic efficiency in the decision making process, a combination of
approaches will probably offer the best result in terms of informing health care policy
makers.
No single country included in our review used a single ICER threshold value. Either an
‘acceptable’ range is defined as in the UK, or no explicit ICER threshold values are used
at all. In most countries, it appears that interventions with a low ICER are more likely to
become accepted than interventions with a high ICER. In the presence of high ICERs,
other assessment elements may become more important.
In Belgium decision making remains mainly an interactive deliberation process, although
efforts are made to ‘rationalise’ the decision making and substantiate reimbursement
requests with scientific evidence. In contrast to clinical effectiveness, cost-effectiveness
is sometimes considered in the decision making process by the DRC but rarely by the
TCI.
A key message we derive from this work is the importance of transparency about the
criteria and social values that are weighed in a health policy making process. Therefore
it is important that the information presented to health care policy makers makes sense
to them, e.g. by presenting the information in disaggregated form in addition to
‘composite’ ICERs.