Peter J. Neumann > Quotes

“value judgment raises important ethical questions. For example, children and the elderly who are not working will not be valued the same as people in the workforce; women may not be valued equally to men. Inclusion of productivity and consumption may result in resource allocations that some observers may consider discriminatory. These are important limitations that analysts and decision makers need to consider carefully. More generally, as an analysis moves from the narrower healthcare sector perspective to the broader societal perspective, more social value judgments of this sort will need to be made. To summarize our Reference Case recommendations in somewhat greater detail, we suggest that analysts include Reference Case analyses from both the healthcare sector perspective and the societal perspective (see Chapter 3 and Recommendations 2–5). Table 4.1 summarizes the cost components included in these two perspectives. The healthcare sector Reference Case includes formal healthcare sector (medical) costs borne by third-party payers plus patients’ out-of-pocket medical costs. Both types of medical expenditures include current and future costs that are related and unrelated to the condition under consideration. We recommend that the results of the healthcare sector Reference Case analysis be summarized in the conventional form, as an ICER. The net monetary benefit (NMB) or net health benefit (NHB) may also be reported, and a range of cost-effectiveness thresholds should be considered. We also recommend that analysts include a Reference Case analysis from a societal perspective (Recommendation 4). A societal perspective is particularly important when interventions are likely to have important effects on sectors of the economy outside of the formal healthcare sector, and when there is a need or desire to understand the wide range of costs and effects. A societal perspective includes medical costs (current and future,”
― Peter J. Neumann, Cost-Effectiveness in Health and Medicine

“perspective is the broadest and most comprehensive perspective, and incorporates all costs and all effects regardless of who incurs the costs and who obtains the effects, and regardless of whether they are health or non-health costs or effects. It includes time costs, transportation costs, and changes in productivity and consumption, as well as other effects in non-healthcare sectors. The societal perspective may be defined by the jurisdiction of the decision maker and the applicability of the decision. Often, it is delimited by national borders; however, the societal perspective should not be confused with a “governmental” perspective, which may include only a subset of costs and effects. Although our recommendations are consistent with the original Panel’s definition of the societal perspective, the cross-sector consequences have seldom been modeled in practice. Our emphasis on including such consequences is an important feature of the new Reference Case recommendations. We recommend that the societal perspective include changes in productivity and consumption. The reason is that health interventions that improve (or decrease) health-related quality of life or that increase length of life may have important effects on the ability of people to participate in the labor force, engage in unpaid volunteer work, or participate in productive work within the household. And because an increase in length of life is accompanied by an increase in consumption in terms of what people spend to live, healthcare interventions may result in changes in both productivity and consumption (Recommendation 4). Productivity is usually measured in terms of wages, and consumption is measured in annual expenditures by age. Analysts should be aware that inclusion of productivity measured by wages reflects a value judgment that productivity is an important and relevant byproduct of health interventions, and may advantage interventions that affect groups of people who can participate in either paid or unpaid work (see Chapter 2). This”
― Peter J. Neumann, Cost-Effectiveness in Health and Medicine

“In non-US settings with single public payers, such as the United Kingdom, Canada, and many European countries, the payer perspective may be the most relevant for healthcare decisions and would typically include a broader array of medical costs, benefits, and harms. As noted above, the US private payer perspective omits an important proportion of medical costs borne by patients, namely, out-of-pocket costs (co-payments and deductibles), as well as time costs incurred by patients and informal (unpaid) caregivers and their transportation costs. In the United States, we call the perspective that includes medical costs borne by both payers and patients the healthcare sector perspective. This is one of two Reference Case analyses recommended here (Recommendations 2–3). Because some interventions also impose significant time costs on patients and informal caregivers, analysts or decision makers may wish to include these costs as well, a perspective we call the healthcare sector with time cost perspective. Quantifying time costs may be relatively straightforward for some interventions but more challenging for others (Russell 2009). Some interventions to improve health may have important consequences outside of the healthcare sector. For example, a successful intervention to treat substance abuse might reduce costs in the criminal justice system. A successful intervention for autism may positively affect educational attainment. Public health interventions may have particularly broad consequences across non-healthcare sectors, including the environment and the criminal justice system. For interventions that have important non-healthcare sector consequences, we recommend that the analyst include such consequences when feasible. We call the perspective that includes all consequences across sectors the societal perspective (Recommendation 4). Thus, the societal”
― Peter J. Neumann, Cost-Effectiveness in Health and Medicine

“Cost-effectiveness analyses can be undertaken from a number of different perspectives. The choice of the study perspective is an important methodological decision because it determines which costs and effects to count and how to value them. The appropriate perspective depends on the objective of the study, the context, and the relevant decision makers. As indicated above, we recommend that analysts conduct Reference Case analyses from both the healthcare sector and societal perspectives (Recommendations 2–5). Other perspectives may, however, be relevant for specific decision makers. To illustrate, we briefly consider four perspectives potentially relevant to the analysis of health interventions: the payer perspective, the healthcare sector Reference Case perspective, the healthcare sector with time cost perspective, and the societal Reference Case perspective. Although we note two additional perspectives here, the remainder of this book will focus on the healthcare sector and societal Reference Case perspectives. The payer perspective includes the consequences that a specific payer considers relevant. This perspective will be more or less narrow depending on whether the payer is private or public. For a US private commercial payer (insurer), for example, costs might include reimbursement for medical care paid for by the insurer and consequences for patients covered by the insurer.”
― Peter J. Neumann, Cost-Effectiveness in Health and Medicine