, Volume 23, Issue 7, pp 639–649 | Cite as

Discounting health effects in pharmacoeconomic evaluations

Current controversies
  • J. M. Bos
  • Maarten J. Postma
  • Lieven AnnemansEmail author
Current Opinion


Currently, much debate still surrounds the discounting of health effects. Most general consensus statements have argued for the same discount rate for health and money; however, this practice has been questioned by several authors. The choice of discount rate can have varying effects on interventions, depending on the disease area. In this paper, we review two major current controversies around discounting: the use of similar or differential discount rates for health and money; and the validity of the underlying discounting model (time preference, constant discounting and the use of aggregated utilities for health effects).

Various arguments justify a different rate of discounting for health effects than for money. Empirical evidence questions the validity of the constant discounting model, pointing out that time preference is not constant and should not be applied as such. Also, the validity of the aggregated utility model for health might be questioned, implying that a life cannot simply be cut into life years as single entities that are discounted back to the net present value. Such debates have led to varying methodologies being employed in economic evaluations, causing difficulties in their interpretation. Although there is sufficient evidence to question the use of similar discount rates for health and money, currently there is not enough information on the nature of the different processes that constitute discounting to reach a solid conclusion on the use of a different method.

The lack of consensus on one of the most important topics in pharmacoeconomics makes the case for a more restricted use of cost-effectiveness or costutility ratios than as the most important singular outcome of pharmacoeconomic studies. Instead, results should be presented in a non-aggregated manner that enables policy makers to value health gains according to timing and to which subpopulation they are accrued in.


Discount Rate Marginal Utility Time Preference Health Gain Market Rate 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



Lieven Annemans and Maarten Postma were supported by an unrestricted grant from GlaxoSmithKline, Germany. Also, both authors have various consultancies and projects for pharmaceutical industries, none of which, however, provides direct conflicts of interest with regard to this work.


  1. 1.
    Gold MR, Siegel JE, Russell LB, et al. Cost-effectiveness in Health and Medicine. New York (NY): Oxford University Press, 1996Google Scholar
  2. 2.
    Lazaro A. Theoretical arguments for the discounting of health consequences; where do we go from here? Pharmacoeconomics 2002; 20: 943–61PubMedCrossRefGoogle Scholar
  3. 3.
    Cohen BJ. Discounting in cost-utility analysis of healthcare interventions: reassessing current practice. Pharmacoeconomics 2003; 21 (2): 75–87PubMedCrossRefGoogle Scholar
  4. 4.
    Beutels P, Edmunds WJ, Antonanzas F, et al. Economic evaluation of vaccination programmes: a consensus statement focusing on viral hepatitis. Pharmacoeconomics 2002; 20 (1): 1–7PubMedCrossRefGoogle Scholar
  5. 5.
    Lipscomb J, Weinstein MC, Torrance GW. Time preference. In: Gold MR, Siegel JE, Russel LB, et al., editors. Cost-effectiveness in Health and Medicine. New York (NY): Oxford University Press, 1996: 214–46Google Scholar
  6. 6.
    van Hour BA. Discounting costs and effects: a reconsideration. Health Econ 1998 Nov; 7 (7): 581–94CrossRefGoogle Scholar
  7. 7.
    Gravelle H, Smith DH. Discounting for health effects in costbenefit and cost-effectiveness analysis. Health Econ 2001; 10: 587–99PubMedCrossRefGoogle Scholar
  8. 8.
    UK Department of Health. Policy appraisal and health. London: Department of Health, 1995Google Scholar
  9. 9.
    Smith DH, Gravelle H. The practice of discounting in economic evaluations of healthcare interventions. Int J Technol Assess Health Care 2001; 17: 236–43PubMedCrossRefGoogle Scholar
  10. 10.
    Struijs IN, de Wit GA, Kretzschmar MEE, et al. Kosten en effecten van algemene vaccinatie tegen hepatitis B. Infectieziekten Bulletin 2000; 11: 109–14Google Scholar
  11. 11.
    Bos JM, Rdmke HC, Welte R, et al. Health economics of a hexavalent meningococcal outer-membrane vesicle vaccine in children: potential impact of introduction in the Dutch vaccination programme. Vaccine 2001; 20: 202–7PubMedCrossRefGoogle Scholar
  12. 12.
    Postma MJ, Heijnen MLA, Jager JC. Cost-effectiveness analysis of pneumococcal vaccination for elderly individuals in The Netherlands. Pharmacoeconomics 2001; 19 (2): 215–22PubMedCrossRefGoogle Scholar
  13. 13.
    Postma MJ, Bos JM, van Gennep M, et al. Economic evaluation of influenza vaccination: assessment for The Netherlands. Pharmacoeconomics 1999; 16 Suppl. 1: 33–40PubMedCrossRefGoogle Scholar
  14. 14.
    Edmunds WJ, Brisson M, Melegaro A, et al. The potential costeffectiveness of acellular pertussis booster vaccination in England and Wales. Vaccine 2002; 20: 1316–30PubMedCrossRefGoogle Scholar
  15. 15.
    Brisson M, Edmunds WJ. The cost-effectiveness of varicella vaccination in Canada. Vaccine 2002; 20: 1113–25PubMedCrossRefGoogle Scholar
  16. 16.
    Skull SA, Butler JR. Meningococcal vaccination for adolescents? An economic evaluation in Victoria. J Paediatr Child Health 2001; 37: S28–33PubMedCrossRefGoogle Scholar
  17. 17.
    Almbrand B, Johannesson M, Sjostrand B, et al. Cost-effectiveness of intense insulin treatment after acute myocardial infarction in patients with diabetes mellitus: results from the DIGAMI study. Eur Heart J 2000; 21: 733–9PubMedCrossRefGoogle Scholar
  18. 18.
    Caro JJ, Klittich WS, Raggio G, et al. Economic assessment of troglitazone as an adjunct to sulfonylurea therapy in the treatment of type 2 diabetes. Clin Ther 2000; 22: 116–27PubMedCrossRefGoogle Scholar
  19. 19.
    CDC Diabetes Cost-Effectiveness Study Group. Centers for Disease Control and Prevention. The cost-effectiveness of screening for type-2 diabetes. JAMA 1998; 280 (20): 1757–63CrossRefGoogle Scholar
  20. 20.
    Eastman RC, Javitt JC, Herman WH, et al. Model of complications of NIDDM: II. Analysis of the health benefits and costeffectiveness of treating NIDDM with the goal of normoglycemia. Diabetes Care 1997; 20 (5): 735–44PubMedCrossRefGoogle Scholar
  21. 21.
    Lamotte M, Annemans L, Lefever A, et al. A health economic model to assess the long-term effects and cost-effectiveness of orlistat in obese type 2 diabetic patients. Diabetes Care 2002; 25 (2): 303–8PubMedCrossRefGoogle Scholar
  22. 22.
    Messori A, Bonistalli L, Costantini M, et al. Cost effectiveness of adjuvant intraportal chemotherapy in patients with colorectal cancer. J Clin Gastroenterol 1996; 23 (4): 269–74PubMedCrossRefGoogle Scholar
  23. 23.
    Beard SM, Holmes M, Price C, et al. Hepatic resection for colorectal liver metastases: a cost-effectiveness analysis. Ann Surg 2000; 232 (6: 763–76PubMedCrossRefGoogle Scholar
  24. 24.
    Lafuma A, Dreno B, Delaunay M, et al. French Cooperative Group on Melanoma. Economic analysis of adjuvant therapy with interferon alpha-2a in stage II malignant melanoma. Eur J Cancer 2001; 37 (3): 369–75PubMedCrossRefGoogle Scholar
  25. 25.
    Messori A, Becagli P, Trippoli S, et al. A retrospective costeffectiveness analysis of interferon as adjuvant therapy in high-risk resected cutaneous melanoma. Eur J Cancer 1997; 33 (9): 1373–9PubMedCrossRefGoogle Scholar
  26. 26.
    Kerlikowske K, Salzmann P, Phillips KA, et al. Continuing screening mammography in women aged 70 to 79 years: impact on life expectancy and cost-effectiveness. JAMA 1999; 282 (22): 2156–63PubMedCrossRefGoogle Scholar
  27. 27.
    Norum J. Adjuvant cyclophosphamide, methotrexate, fluorouracil (CMF) in breast cancer: is it cost-effective? Acta Oncol 2000; 39 (1): 33–9PubMedCrossRefGoogle Scholar
  28. 28.
    Gyrd-Hansen D, Søgaard J. Discounting life-years: whither time preference? Health Econ 1998; 7 (2): 121–7PubMedCrossRefGoogle Scholar
  29. 29.
    Parsonage M, Neuburger H. Discounting and health benefits. Health Econ 1992; 1: 71–9PubMedCrossRefGoogle Scholar
  30. 30.
    Robinson JC. Philosophical origins of the social rate of discount in cost-benefit analysis. Milbank Q 1990; 68: 245–64PubMedCrossRefGoogle Scholar
  31. 31.
    Lesser JA, Zerbe RO. Discounting procedures for environmental (and other) projects: a comment of Kolb and Scheraga. J Policy Anal Manage 1994; 13: 140–56CrossRefGoogle Scholar
  32. 32.
    Arrow KJ, Kurtz M. Public investment, the rate of return, and optimal fiscal policy. Baltimore (MD): Johns Hopkins University Press, 1970Google Scholar
  33. 33.
    Keeler EB, Cretin S. Discounting of life-saving and other nonmonetary effects. Manage Sci 1983; 29: 300–6CrossRefGoogle Scholar
  34. 34.
    Weinstein MC, Stason WB. Foundations of cost-effectiveness analysis for health and medical practices. N Engl J Med 1977; 296 (13): 716–21PubMedCrossRefGoogle Scholar
  35. 35.
    Olsen JBA. On what basis should health be discounted? J Health Econ 1993; 12: 39–53PubMedCrossRefGoogle Scholar
  36. 36.
    Goodin RE. Discounting discounting. J Public Policy 1982; 2: 257–65Google Scholar
  37. 37.
    Parfit D. Reasons and Persons. Oxford: Oxford University Press, 1984Google Scholar
  38. 38.
    Hume D. A Treatise of Human Nature. 1739, Reprint. London: Oxford University Press, 1968: 537Google Scholar
  39. 39.
    Pigou AC. The Economics of Welfare. 1920, Reprint. London: Macmillan, 1960Google Scholar
  40. 40.
    Klose T. A utility-theoretic model for QALYs and willingness to pay. Health Econ 2003; 12 (1): 17–31PubMedCrossRefGoogle Scholar
  41. 41.
    NICE (National Institute for Clinical Excellence). Guidelines [online]. Available from URL: [Accessed 2004 Jan 1]Google Scholar
  42. 42.
    Bleichrodt H, Gafni A. Time preference, the discounted utility model and health. J Health Econ 1996; 15: 49–66PubMedCrossRefGoogle Scholar
  43. 43.
    Loewenstein G. Choice Over Time. New York (NY): Russell Sage Publications, 1992Google Scholar
  44. 44.
    Cairns JA, van der Pol MM. Saving future live years, a comparison of three discounting models. Health Econ 1997; 6: 341–50PubMedCrossRefGoogle Scholar
  45. 45.
    Ariely D, Loewenstein G. When does duration matter in judgment and decision making? J Exp Psychol 2000; 129 (4): 508–23CrossRefGoogle Scholar
  46. 46.
    Kamm FM. Morality, Mortality, vol. 1. New York (NY): Oxford University Press, 1993Google Scholar
  47. 47.
    O’Brien BJ, Gertsen K, Willan AR, et al. Is there a kink in consumers’ threshold value for cost-effectiveness in health care? Health Econ 2002; 11 (2): 175–80PubMedCrossRefGoogle Scholar
  48. 48.
    Meer J, Miller DL, Rosen HS. Exploring the health-wealth nexus. J Health Econ 2003; 22: 713–30PubMedCrossRefGoogle Scholar
  49. 49.
    Ettner S. New evidence on the relationship between income and health. J Health Econ 1996; 15: 67–85PubMedCrossRefGoogle Scholar
  50. 50.
    Wu S. The effects of health events on the economic status of married couples. J Hum Resour 2003; 38: 219–30CrossRefGoogle Scholar
  51. 51.
    Barsky RB, Juster FT, Kimball MS, et al. Preference parameters and behavioral heterogeneity: an experimental approach in the health and retirement study. Q J Econ 1997; 112: 537–79CrossRefGoogle Scholar
  52. 52.
    Johannesson M. On the discounting of gained life-years in costeffectiveness analysis. Int J Technol Assess Health Care 1992; 8: 359–64PubMedCrossRefGoogle Scholar
  53. 53.
    Mauskopf JA, Paul JE, Grant DM, et al. The role of costconsequence analysis in healthcare decision-making. Pharmacoeconomics 1998; 13 (3): 277–88PubMedCrossRefGoogle Scholar

Copyright information

© Adis Data Information BV 2005

Authors and Affiliations

  • J. M. Bos
    • 1
    • 2
  • Maarten J. Postma
    • 1
  • Lieven Annemans
    • 3
    • 4
    Email author
  1. 1.Groningen University Institute for Drug Exploration (GUIDE) Department of Social Pharmacy, Pharmacoepidemiology and PharmacotherapyGroningenThe Netherlands
  2. 2.Netherlands Vaccine InstituteBilthovenThe Netherlands
  3. 3.Department of Public HealthGhent UniversityGhentBelgium
  4. 4.IMS Health/Health Economics and Disease Management (HEDM)BrusselsBelgium

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