Resolving the "Cost-Effective but Unaffordable" Paradox: Estimating the Health Opportunity Costs of Nonmarginal Budget Impacts.
Resolving the "Cost-Effective but Unaffordable" Paradox: Estimating the Health Opportunity Costs of Nonmarginal Budget Impacts.
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DOI：
10.1016/j.jval.2017.10.006
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发表时间：
2018-03-01
期刊：
影响因子：
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通讯作者：
Soares, Marta
中科院分区：
文献类型：
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作者：
Lomas, James;Claxton, Karl;Soares, Marta
考虑一项拟议的投资（干预措施、技术或护理计划）是否负担得起，实际上是在问它提供的好处是否大于它的机会成本。如果说一项投资具有成本效益，但负担不起，那一定意味着用来判断成本效益的（隐性或显性）“门槛”并不反映机会成本的规模和价值。现有的健康机会成本的经验估计是基于跨部门的支出和死亡率的变化结果的方案预算类别（PBC），并没有反映可能的影响，非边际预算的影响健康机会成本。联合王国卫生部定期更新国家卫生服务（NHS）地方地区基于需求的资源目标分配，创建两个地方地区分组（低于目标分配的地区和超过目标分配的地区）。这些数据提供了机会，探讨如何在医疗保健支出的变化与可用资源的影响不同。我们使用2008-2009年的数据来评估两种计量经济学方法来估计，并探索一系列标准，以接受23个PBC中支出和结局弹性差异的亚组特定效应。我们的研究结果表明，健康的机会成本所产生的投资强加的支出净增加被低估，除非考虑到可能的非边际效应。他们还表明，能够“平滑”这些非边际预算的影响，通过医疗保健系统对未来的预算或从制造商提供“抵押”类型的安排借款的好处（减少健康的机会成本或增加基于价值的价格的技术）。
Considering whether or not a proposed investment (an intervention, technology, or program of care) is affordable is really asking whether the benefits it offers are greater than its opportunity cost. To say that an investment is cost-effective but not affordable must mean that the (implicit or explicit) "threshold" used to judge cost-effectiveness does not reflect the scale and value of the opportunity costs. Existing empirical estimates of health opportunity costs are based on cross-sectional variation in expenditure and mortality outcomes by program budget categories (PBCs) and do not reflect the likely effect of nonmarginal budget impacts on health opportunity costs. The UK Department of Health regularly updates the needs-based target allocation of resources to local areas of the National Health Service (NHS), creating two subgroups of local areas (those under target allocation and those over). These data provide the opportunity to explore how the effects of changes in health care expenditure differ with available resources. We use 2008-2009 data to evaluate two econometric approaches to estimation and explore a range of criteria for accepting subgroup specific effects for differences in expenditure and outcome elasticities across the 23 PBCs. Our results indicate that health opportunity costs arising from an investment imposing net increases in expenditure are underestimated unless account is taken of likely nonmarginal effects. They also indicate the benefits (reduced health opportunity costs or increased value-based price of a technology) of being able to "smooth" these nonmarginal budget impacts by health care systems borrowing against future budgets or from manufacturers offering "mortgage" type arrangements.