, Volume 35, Issue 1, pp 5–13 | Cite as

Discounting the Recommendations of the Second Panel on Cost-Effectiveness in Health and Medicine

  • Mike PauldenEmail author
  • James F. O’Mahony
  • Christopher McCabe
Leading Article


Twenty years ago, the “Panel on Cost-effectiveness in Health and Medicine” published a landmark text setting out appropriate methods for conducting cost-effectiveness analyses of health technologies. In the two decades since, the methods used for economic evaluations have advanced substantially. Recently, a “second panel” (hereafter “the panel”) was convened to update the text and its recommendations were published in November 2016. The purpose of this paper is to critique the panel’s updated guidance regarding the discounting of costs and health effects. The advances in discounting methodology since the first panel include greater theoretical clarity regarding the specification of discount rates, how these rates vary with the analytical perspective chosen, and whether the healthcare budget is constrained. More specifically, there has been an important resolution of the debate regarding the conditions under which differential discounting of costs and health effects is appropriate. We show that the panel’s recommendations are inconsistent with this recent literature. Importantly, the panel’s departures from previously published findings do not arise from an alternative interpretation of theory; rather, we demonstrate that this is due to fundamental errors in methodology and logic. The panel also failed to conduct a formal review of relevant empirical evidence. We provide a number of suggestions for how the panel’s recommendations could be improved in future.


Discount Rate Incremental Cost Marginal Utility Time Preference Future Consumption 
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Compliance with Ethical Standards

Conflict of interest

The authors have no relevant conflicts of interest.


  1. 1.
    Gold MR, Siegel JE, Russell LB, Weinstein MC. Cost-effectiveness in health and medicine: report of the panel on cost-effectiveness in health and medicine. 2nd edition. New York: Oxford University Press; 1996.Google Scholar
  2. 2.
    Neumann PJ, Sanders GD, Russell LB, Siegel JE, Ganiats TG, editors. Cost-effectiveness in health and medicine. Second edition. 2nd edition. New York: Oxford University Press; 2016.Google Scholar
  3. 3.
    Brouwer WB, Niessen LW, Postma MJ, Rutten FF. Need for differential discounting of costs and health effects in cost effectiveness analyses. BMJ. 2005;331(7514):446–8. doi: 10.1136/bmj.331.7514.446.CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Claxton K, Sculpher M, Culyer A, McCabe C, Briggs A, Akehurst R, et al. Discounting and cost-effectiveness in NICE—stepping back to sort out confusion. Health Econ. 2006;15(1):1–4. doi: 10.1002/hec.1081.CrossRefPubMedGoogle Scholar
  5. 5.
    Gravelle H, Brouwer W, Niessen L, Postma M, Rutten F. Discounting in economic evaluations: stepping forward towards optimal decision rules. Health Econ. 2007;16(3):307–17. doi: 10.1002/hec.1168.CrossRefPubMedGoogle Scholar
  6. 6.
    Claxton K, Paulden M, Gravelle H, Brouwer W, Culyer AJ. Discounting and decision making in the economic evaluation of health-care technologies. Health Econ. 2011;20(1):2–15. doi: 10.1002/hec.1612.CrossRefPubMedGoogle Scholar
  7. 7.
    Paulden M, Claxton K. Budget allocation and the revealed social rate of time preference for health. Health Econ. 2012;21(5):612–8. doi: 10.1002/hec.1730.CrossRefPubMedGoogle Scholar
  8. 8.
    HM Treasury. The green book: appraisal and evaluation in central government. London: HM Treasury; 2003.Google Scholar
  9. 9.
    Paulden M, O'Mahony J, McCabe C. Determinants of change in the cost-effectiveness threshold. Med Decis Mak. 2016. doi: 10.1177/0272989X16662242.Google Scholar
  10. 10.
    Shiroiwa, T, Fukuda T, Ikeda S, Takura T, Moriwaki K. Development of an official guideline for the economic evaluation of drugs/medical devices in Japan. Value in Health. 2016. doi: 10.1016/j.jval.2016.08.726.
  11. 11.
    Canadian Agency for Drugs and Technologies in Health. Update to guidelines for the economic evaluation of health technologies: Canada. 4th edition. Draft—For Stakeholder Feedback. Ottawa: CADTH; 2016.Google Scholar
  12. 12.
    Office of Management and Budget. Circular A-94 Appendix C, Revised November 2015. Washington DC: OMB; 2015. Available from
  13. 13.
    Nord E. Discounting future health benefits: the poverty of consistency arguments. Health Econ. 2011;20(1):16–26. doi: 10.1002/hec.1687.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing Switzerland 2016

Authors and Affiliations

  1. 1.School of Public HealthUniversity of AlbertaEdmontonCanada
  2. 2.Centre for Health Policy and Management, School of MedicineTrinity College DublinDublinIreland
  3. 3.Department of Emergency MedicineUniversity of AlbertaEdmontonCanada

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