Priority setting with economic constraints: Opportunities ...

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


• 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


“Theoretical dissonance” & the need for a broader approach


Choices in health & care


$

£

€

Benefit

http://www.plain.sa.gov.au/%7Eopinact/cart_doc.jpg


$

£

€



$

£

€

Benefit as health

Health



$

£

€

Benefit as QALYs



Health


HealthQALYs


QALYs


Health


Beyond health

Wellbeing


Beyond the patient

Wellbeing

Family,Carers


Society

Beyond the patient

Wellbeing

Family,Carers

Society


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


Increasing evidence that a focus on health alone is not enough…

… an easy, but poor, normative assumption


“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


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?


• 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


Opportunities and opportunity costs of a broader approach


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


More meaningful

ICERS


But also opportunities

Opportunity costs for carers

Carer Experience Scale

See: www.birmingham.ac.uk/icecap

http://www.birmingham.ac.uk/icecap


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


More meaningful

ICERS


Opportunities and opportunity costs of a capability approach


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

Presentatör

Presentationsanteckningar

The question then iin how do we measure within this framework, and The second INNOVATIVE aspect of the proposed work is therefore in its choice of evaluative space – or what we measure If we think about hospice provision, for example, we could evaluative it in a number of ways In terms of health – but already noted that the problem with this is that it is measuring the wrong thing How much utility – or pleasure – it brings. This is what is used in most of economics, but the problem here is that people might gradually ADAPT to a poor state of well-being as they become nearer to end of life. They may then over-value their state and under-value improvements in that state because they have got used to it Another alternative is to look at capability - what people are able to do or be – this reduces the problem of adaptation because it is more objecive; it also allows for freedom – so if a hospice service enables people to make preparations for death such as saying goodbye to loved ones or making a will, this service is seen as positive whehter or not people choose to use it. This notion of capability is put forward by nobel prize winning economist Amartya Sen & is gaining importance as an approach to economic evaluation in health economics PARTICULARLY LENDS ITSELF TO END OF LIFE CARE BECAUSE OF THESE ISSUES OF ADAPTATION, AND CHOICE WHICH MAY BE PARTICULARLY IMPORTANT AT END OF LIFE


Opportunity 2: find out!

Sen:advocates a

participatory approach to finding

out what capabilities are

important to people


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


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

Presentatör

Presentationsanteckningar

Descriptive system based on in-depth interviews Regarding relevant attributes Regarding meaningful language


• 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


• Shakespeare’s seven ages of man…

Opportunity 3: a life course approach


An integrated framework

Birth Death

ICECAP-A ICECAP-O

ICECAP-SCM

6518

ICECAP-Cs

• Similar basis for descriptive systems

• Similar valuation mechanisms

• Similar anchors


• 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


• 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


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.


• 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


The opportunity cost of politics… “disregarding the first lesson of

economics” (scarcity)

… but is it just politics?


A SYSTEM OF EQUIVOCATION IN WHICH RESPONSIBILITY FOR MAKING THE

DIFFICULT DECISIONS WAS AVOIDED OR AMELIORATED


“One of the key issues is about trying to be as objective as possible and avoid making

decisions on an emotional base”


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…”


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”


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”


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.


• 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


And finally...


Werner’s quote

Economics is extremely useful as a form of employment for economists.


An adaptation?

Economic evaluation is extremely useful as a form of employment for health economists.


• “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)


Is there an opportunity cost to prioritising economic evaluation as our form of

priority setting?


Should economists be focusing more on

approaches to priority setting that might have

broader impact?


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


@ICECAPm

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