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

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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.
KCE reports 100 ICER Thresholds 61 6 RECOMMENDATIONS • Cost-effectiveness should be a criterion in the decision making process, as ignoring economic efficiency is unethical. Dossiers submitted to support policy makers should therefore always include an economic evaluation. • Economic models should be reported in a transparent way, presenting all information used in the model in a way that allows the policy makers to verify the assumptions, view the uncertainties and weigh the importance of the assumptions and uncertainties for the decision. Transparency and control of economic models is crucial to increase their credibility. • The results of economic evaluations should be presented in disaggregated form. This includes “unpacking” the ICER but also presenting other economically relevant outcome parameters that can be derived from the economic evaluation but that are not necessarily visible in the ICER estimate. • Alongside the disaggregated presentation of economically important elements, also the ICER should continue to be presented, calculated following standard methodological guidelines. • Scientific research should continue to be used in the decision making processes on the allocation of health care resources. It will allow policy makers to back up arguments in favour of or against a particular decision by scientific evidence. • Decision makers should be more transparent in their decision making criteria and the relative importance of the different criteria in each decision.
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Valeurs seuils pour le rapport coût-efficacité en soins de santé - KCE

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