Priority setting with economic constraints: Opportunities, and opportunity costs…
Joanna CoastPRIORITIES 2018, Linköping, September 2018
Priorities: opportunities & opportunity costs
Broadening the evaluative
scope Decision frameworks &
equity
Values & value judgements
Priorities: opportunities & opportunity costs
• The opportunity cost of “theoretical dissonance” in economic evaluation
• Opportunities and opportunity costs of broader & capability approaches in prioritising health & care services
• Opportunity costs of …“disregarding the first lesson of economics” in decision frameworks advocated by health economists
• And finally…• the opportunity cost of economic evaluation itself…
Outline
Priorities: opportunities & opportunity costs
“Theoretical dissonance” & the need for a broader approach
Priorities: opportunities & opportunity costs
Choices in health & care
Priorities: opportunities & opportunity costs
$
£
€
Benefit
Priorities: opportunities & opportunity costs
$
£
€
Priorities: opportunities & opportunity costs
$
£
€
Benefit as health
Health
Priorities: opportunities & opportunity costs
$
£
€
Benefit as QALYs
Priorities: opportunities & opportunity costs
Health
Priorities: opportunities & opportunity costs
HealthQALYs
Priorities: opportunities & opportunity costs
QALYs
Priorities: opportunities & opportunity costs
QALYs
Priorities: opportunities & opportunity costs
QALYs
Priorities: opportunities & opportunity costs
Health
Priorities: opportunities & opportunity costs
Health
Priorities: opportunities & opportunity costs
Beyond health
Wellbeing
Priorities: opportunities & opportunity costs
Beyond the patient
Wellbeing
Family,Carers
Priorities: opportunities & opportunity costs
Society
Beyond the patient
Wellbeing
Family,Carers
Society
Priorities: opportunities & opportunity costs
An example: policy decisions around end of life
6E68: …end of life care’s different from everything
else in that you’re not making a person better,
you’re just making a person comfortable and happy…
6E69: I’d argue that the guiding principle should be need… and compassion. If I were a policy maker I’d be
looking at that
6C3: … [families] haven’t always got the support … sometimes it’s not enough, it’s not enough at all
Priorities: opportunities & opportunity costs
Increasing evidence that a focus on health alone is not enough…
… an easy, but poor, normative assumption
Priorities: opportunities & opportunity costs
Increasing evidence that a focus on health alone is not enough…
… an easy, but poor, normative assumption
Priorities: opportunities & opportunity costs
“Consider someone who buys an expensive car but discovers that it is not comfortable on long drives. Dissonance exists between their beliefs that they have bought a good car and that a good car should be comfortable. Dissonance could be eliminated by• deciding that it does not matter since the car is mainly used for
short trips (reducing the importance of the dissonant belief) • or focusing on the car’s strengths such as safety, appearance,
handling (thereby adding more consonant beliefs).
The dissonance could also be eliminated by getting rid of the car, but this behaviour is a lot harder to achieve than changing beliefs.”
(InstructionalDesign.org)
Cognitive dissonance
Priorities: opportunities & opportunity costs
Consider someone who conducts QALY-based extra-welfaristeconomic evaluation, but discovers that it works poorly for social care evaluations. Dissonance exists between their beliefs that QALYs are a good outcome for economic evaluation and that QALYs work poorly for social care. Dissonance could be eliminated by• deciding that it does not matter since most economic evaluation
is in health care (reducing the importance of the dissonant belief) • or focusing on the QALY’s strengths such as consistency,
simplicity, validity (thereby adding more consonant beliefs).
The dissonance could also be eliminated by getting rid of the QALY, but this behaviour is a lot harder to achieve than changing beliefs….
Theoretical dissonance in EE?
Priorities: opportunities & opportunity costs
• In normative economics…• E.g. we move to extra-welfarist QALYs but leave a
decision rule based on welfarist maximisation without much thought
• E.g. we obsess about ‘accurate’ preference based values for QALYs, but largely use arbitrary values for time preference
• E.g. even in Werner’s talk – societal (welfarist) approach with population QALYs (extra-welfarist…)
Theoretical dissonance pervasive
Priorities: opportunities & opportunity costs
Opportunities and opportunity costs of a broader approach
Priorities: opportunities & opportunity costs
More meaningful
ICERS
Priorities: opportunities & opportunity costs
More meaningful
ICERS
• Opportunity costs from Schools’ perspectives• Loss of academic time
• “So I mean obviously, I have to decide whether I feel that the intervention is going to be of any benefit to the children, mainly academically because I think that’s our reason to be here”
• “I’ll say how often have they ran this week and they’ll say ‘oh, it’s only been once this week because of such and such…’ I would say probably 2 to 3 times a week”
Katie Breheny, Peymane Adab, Sandra Passmore, Emma Lancashire, Joanna Coast, IestynWilliams, Emma Frew
Priorities: opportunities & opportunity costs
More meaningful
ICERS
Priorities: opportunities & opportunity costs
But also opportunities
Opportunity costs for carers
Carer Experience Scale
See: www.birmingham.ac.uk/icecap
Priorities: opportunities & opportunity costs
Who should be included as close persons?
On average, eight close-persons included
Typically, there were three within the inner circle
Alastair Canaway, Hareth Al-Janabi, Phil Kinghorn, Cara Bailey, Joanna Coast
• Use of hierarchical mapping
Priorities: opportunities & opportunity costs
More meaningful
ICERS
Priorities: opportunities & opportunity costs
Opportunities and opportunity costs of a capability approach
Priorities: opportunities & opportunity costs
Opportunity 1: a broader evaluative space
GOOD: hospice
provision
UTILITY: pleasure
obtained from receiving the
care
HEALTH: improvements in morbidity and mortality
CAPABILITY: what you are able to do or be
e.g. ability to make preparations
Priorities: opportunities & opportunity costs
Opportunity 2: find out!
Sen:advocates a
participatory approach to finding
out what capabilities are
important to people
Priorities: opportunities & opportunity costs
The value of capability
I lost all my friends when I couldn’t go
out – for seven years I was looking after
both my husband and my mother who was
beginning to go senile
I can choose what I want to do, I can
choose my friends, I can choose who I want
to do things with
Fortunate in so far as that we’ve
got the two pensions we’re able to go off… we grabbed a
cheapie flight at the end of
April…
For the first time in my life I am dependent, which is not very pleasant…I can’t go
out as I did a few years ago - take the car and go
swimming
Priorities: opportunities & opportunity costs
The value of care
Making sure … things like your bodily functions, to make sure
that’s done and to make sure you don’t lie in a wet bed and things
like that.
Being clean, number one, not being in any of your own mess
whatsoever
I’ve got my self-respect, she [carer] doesn’t stand there if I’m having a shower and all that, she just makes sure the
windows are covered … we all want our self-respect no matter
who we are
Priorities: opportunities & opportunity costs
• ICECAP-A• 5 questions, each with 4 possible responses• Aims to tap into what is important to the general
adult population
• ICECAP-O• 5 questions, each with 4 response categories• 1024 possible capability wellbeing’ states
• ICECAP-SCM• 7 question, each with 4 possible responses
Generation of ICECAP measures
Priorities: opportunities & opportunity costs
• Shakespeare’s seven ages of man…
Opportunity 3: a life course approach
Priorities: opportunities & opportunity costs
An integrated framework
Birth Death
ICECAP-A ICECAP-O
ICECAP-SCM
6518
ICECAP-Cs
• Similar basis for descriptive systems
• Similar valuation mechanisms
• Similar anchors
Priorities: opportunities & opportunity costs
An integrated framework
Birth Death
ICECAP-A ICECAP-O
ICECAP-SCM
6518
ICECAP-Cs
• Similar basis for descriptive systems
• Similar valuation mechanisms
• Similar anchors
Priorities: opportunities & opportunity costs
• Assessing sufficient capability: A new approach to economic evaluation• Paul Mark Mitchell, Tracy E. Roberts, Pelham M.
Barton, Joanna Coast• Social Science & Medicine 139 (2105) 71-79
Opportunity 4: explicit equity focus
Priorities: opportunities & opportunity costs
• Loss of comparability and consistency in decision making• Werner suggested important to look at wellbeing
‘some of the time’ – consistency?• Deciding scope of different ‘spaces’
Opportunity costs of capability evaluative space
Priorities: opportunities & opportunity costs
NICE – position statement on EQ-5D-5L values
• Position StatementCurrently the 5L valuation set is not recommended for use. Companies, academic groups and others preparing evidence submissions for NICE should:
• Use the 3L valuation set for reference-case analyses.• If data were gathered using the EQ-5D-5L descriptive
system, reference case analyses should calculate values by mapping the 5L descriptive system data onto the 3L valuation set.
Priorities: opportunities & opportunity costs
• Loss of comparability and consistency in decision making• Werner suggested important to look at wellbeing
‘some of the time’ – consistency?
• Deciding scope of different ‘spaces’• Different approach to anchoring
• capability anchored against full capability and no capability, rather than against death
• Greater complexity…
Opportunity costs of capability evaluative space
Priorities: opportunities & opportunity costs
The opportunity cost of politics… “disregarding the first lesson of
economics” (scarcity)
… but is it just politics?
Priorities: opportunities & opportunity costs
Priorities: opportunities & opportunity costs
A SYSTEM OF EQUIVOCATION IN WHICH RESPONSIBILITY FOR MAKING THE
DIFFICULT DECISIONS WAS AVOIDED OR AMELIORATED
Priorities: opportunities & opportunity costs
“One of the key issues is about trying to be as objective as possible and avoid making
decisions on an emotional base”
Priorities: opportunities & opportunity costs
Dual accountability & vested interests:“absence of local democracy and the national accountability a rather uncomfortable position”
“…the classic sort of shroud waving. And unfortunately we do give in to them…”
Priorities: opportunities & opportunity costs
Dilution of decisions “You transfer money in as legal a way as possible... if you’ve got an acute service where people are dying.”
“A nurse or a doctor is there to care for an individual and do everything that is necessary”
Priorities: opportunities & opportunity costs
COLLUSION“We don't make the real decisions about where the money gets spent… That's a matter for the trust.”
“We don’t say… you may not prescribe… We are not able to provide additional funds… But if you can do it
within your budget, that is your business not ours”
Priorities: opportunities & opportunity costs
Health Economics paper, 2001
At all levels of the decision making process, agents are keen to allow decisions to be passed onto other
levels of decision making, a process which can be explained by the attempt
to avoid the distress, or disutility, associated with the denial of care.
Priorities: opportunities & opportunity costs
• By economists?• With respect to thresholds used in countries
such as UK and Netherlands?• Clearly set at a point above opportunity costs of
services displaced at local health care level…
Avoidance of responsibility
Priorities: opportunities & opportunity costs
And finally...
Priorities: opportunities & opportunity costs
Werner’s quote
Economics is extremely useful as a form of employment for economists.
Priorities: opportunities & opportunity costs
An adaptation?
Economic evaluation is extremely useful as a form of employment for health economists.
Priorities: opportunities & opportunity costs
• “Setting priorities implicitly and explicitly through coverage, (co)payments, budgets, incentives, waiting times, formal vs informal care, quality…
• Here, focus on coverage/funding decisions of health technologies” (Werner slides)
Priorities: opportunities & opportunity costs
Is there an opportunity cost to prioritising economic evaluation as our form of
priority setting?
Priorities: opportunities & opportunity costs
Should economists be focusing more on
approaches to priority setting that might have
broader impact?
Priorities: opportunities & opportunity costs
Acknowledgements:
ICECAP Research team Hareth Al-JanabiCara BaileyAlastair CanawayTerry FlynnPhil KinghornSam HusbandsTom KeeleyPaul MitchellRosanna Orlando
CollaboratorsKathy Armour, John Brazier, Stirling Bryan, Sarah Byford, Sam Clemens, Ini Grewal, Elizabeth Hunyh, Louise Jones, Jane Lewis, Alison Moody, Lucy Natarajan, Tim Peters, Jeff Round, Kerry Sproston
Advisory GroupsICEPOPICECAP-AEconEndLifeLifeCourseCap
Priorities: opportunities & opportunity costs
@ICECAPm