Explicit Cost-Effectiveness Thresholds in Health Care: A Kaleidoscope
Although the principles of cost-effectiveness analysis have been adopted by health systems worldwide, a large majority of countries remain reluctant to specify explicit threshold values for cost-effectiveness. Nonetheless, by aiming to benchmark what counts as a reasonable ‘price’ for health gains, the threshold value is a linchpin in the framework of health technology assessment, albeit also a controversial one. The desirability of thresholds depends largely on three claims: their intention to make resource allocation more efficient, their aspiration to make decision-making more transparent and their objective to make healthcare systems more sustainable. In this paper, we draw from various disciplines such as health economics but also psychology, anthropology, sociology, political sciences and ethics to discuss the many facets of these three values, related to the threshold debate. We discuss issues of allocative efficiency, fair decision-making, realpolitik, taboos, institutional justice and the rule of rescue. Based upon these considerations, which together substantiate the precautionary principle, we conclude that the case against thresholds is stronger than the case in favor and that most countries are right to be reluctant to use explicit threshold values.
KeywordsThresholds Value of health Resource allocation Cost-effectiveness Ethics Health care
Previous versions of this paper were presented at the Annual Conference of the European Association of Centers for Medical Ethics (EACME) in Leuven, September 2016, at the international symposium on ‘Violence of Money’ organized by the Institute of Philosophy (University of Leuven) in January 2018, at the international workshop on ‘Ethics and Economics of Health Care’ organized by Tilburg University in March 2018 and at the international Intensive Course on ‘Justice and Priority Setting in Health Care’ in March 2018. We are grateful to all the participants of these meeting, for their inspiring comments on earlier thoughts. Special thanks goes to: Arnold Burms, Roger Burggraeve, Herman De Dijn, Bart Engelen, Dan Hausman, Erik Schokkaert, Paul Schotsmans, Ruud Termeulen, Antoon Vandevelde and Marcel Verweij. Each of them have, in own and various ways, inspired us to tackle this issue from a multidimensional kaleidoscope perspective and convinced us of the significance of doing it this way.
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Conflict of interest
The authors declare that they have no conflict of interest.
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