Abstract
This paper outlines recent advances in the methods of cost-benefit analysis (CBA). Economic evaluations in healthcare can be criticised for, amongst other things, the inappropriate use of incremental cost-effectiveness ratios and the reporting of benefits in terms of cost savings, such as treatment costs averted. Many such economic evaluations are, according to the ‘scientific’ definition, CBAs. The ‘balance-sheet’ (or opportunity cost) approach is a form of CBA which can be used to identify who bears the costs and who reaps the benefits from any change. Whilst the next stage in a CBA, as defined in health economics, would require that all costs and benefits be valued in monetary terms, the balance-sheet approach, however, advocates that available monetary values can be augmented by other measures of cost and benefit. As such, this approach, which has a theoretical basis, is proposed as a practical prescription for CBA and highlights the notion that unquantified benefits are important and can be included within CBAs even when monetarisation is not possible.
Recent methodological developments in monetary valuation for use in CBA are the development of the technique of willingness to pay, the use of conjoint analysis (CA) to elicit willingness-to-pay (WTP) values and advances in the debate on the inclusion of production gains in CBAs. Whilst acknowledging that there have been developments in each of these areas, it is claimed there has also been progress in using CBA as a framework for evaluation, as reflected by the balance-sheet approach.
The paper concludes by stating that almost all types of economic evaluation have an element of the ‘cost-benefit’ approach in them. The important issue is to focus on the policy question to be addressed and to outline the relevant costs and benefits in a manner which assists the evaluation of welfare changes resulting from changes in healthcare delivery. The focus should not be on moulding a question to fit a hybrid definition of an analytical technique.
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References
Birch S, Gafni A. Cost effectiveness/utility analyses: do current decision rules lead us to where we want to be? J Health Econ 1992; 11: 279–96
Birch S, Gafni A. Cost-effectiveness ratios: in a league of their own. Health Policy 1994; 28: 133–41
Gerard K, Mooney GH. QALY league tables: handle with care. Health Econ 1993; 2 (1): 59–64
Donaldson C. The (near) equivalence of cost-effectiveness and cost-benefit analyses: fact or fallacy? Pharmacoeconomics 1998; 13 (4): 389–96
Johannesson M, Jonsson B. Economic evaluation in health care: is there a role for cost-benefit analysis? Health Policy 1991; 17: 1–23
Robinson R. Cost-benefit analysis. BMJ 1993; 307: 924–6
Hutton J. Cost-benefit analysis in health care expenditure decision making [editorial]. Health Econ 1992; 1: 213–6
Diener A, O’Brien B, Gafni A. Health care contingent valuation studies: a review and classification of the literature. Health Econ 1998; 7: 313–26
Lichfield N. Economics in town planning. Town Planning Rev 1968; (38): 5–20
Michel BC, Seerden RJ, Rutten FFH, et al. The cost effectiveness of diagnostic strategies in patients with suspected pulmonary embolism. Health Econ 1996; 5: 307–18
Kuntz KM, Tsevat J, Goldman L, et al. Cost-effectiveness of routine coronary angiography after acute myocardial infarction. Circulation 1996; 94: 957–65
Johannesson M, Jonsson B, Kjekshus J, et al. Cost effectiveness of simvastatin treatment to lower cholesterol levels in patients with coronary heart disease. N Engl J Med 1997; 336: 332–6
Mark DB, Hlatky MA, Califf RM, et al. Cost effectiveness of thrombolytic therapy with tissue plasminogen activator as compared with streptokinase for acute myocardial infarction. N Engl J Med 1995; 332: 1418–24
Mishan EJ. Cost benefit analysis. London: Unwin Hyman Ltd, 1971
Dreze J, Stern N. The theory of cost-benefit analysis. In: Asuerbach AJ, Feldstein M, editors. Handbook of public economics. Vol. II. Amsterdam: Elsevier Science Publishers, 1987
Zarnke KB, Levine MAH, O’Brien BJ. Cost-benefit analyses in the health care literature: don’t judge a study by its label. J Clin Epidemiol 1997; 50 (7): 813–22
Jackson LA, Schuchat A, Gorsky RD, et al. Should college students be vaccinated against meningococcal disease? A cost-benefit analysis. Am J Pub Health 1995; 85: 843–5
Cookson ST, Stamboulian D, Demonte J, et al. A cost-benefit analysis of programmatic use of CVD 103-HgR live oral cholera vaccine in a high risk population. Int J Epidemiol 1997; 26 (1): 212–9
Legg RF, Sclar DA, Nemec NL, et al. Cost benefit of sumatripan to an employer. J Occup Environ Med 1997; 39 (7): 652–7
Birch S, Donaldson C. Applications of cost-benefit analysis to health care: departures from welfare economic theory. J Health Econ 1987; 6: 211–25
Donaldson C, Shackley P. Economic evaluation. In: Detels R, Holland WW, Mcewen J, et al., editors. Oxford textbook of public health. Vol. 2: the methods of public health. 3rd ed. Oxford: Oxford University Press, 1997: 849–71
Williams A. The cost-benefit approach. Br Med Bull 1974; 30 (3): 252–6
Sugden R, Williams A. The principles of practical cost-benefit analysis. Oxford: Oxford University Press, 1978
Culyer AJ. Economics. Oxford: Blackwell, 1985
Gramlich EM. A guide to benefit-cost analysis. 2nd ed. Englewood Cliffs (NJ): Prentice Hall, 1997
Busschbach JJV, Brouwer WBF, van der Donk, et al. An outline for a cost-effectiveness analysis of a drug for patients with Alzheimer’s disease. Pharmacoeconomics 1998; 13: 21–34
Mauskopf JA, Paul JE, Grant DM, et al. The role of cost-consequence analysis in healthcare decision-making. Pharmacoeconomics 1998; 13 (3): 277–88
Donaldson C, Thomas R, Torgerson DJ. Validity of open-ended and payment scale approaches to eliciting willingness to pay. Appl Econ 1997; 29: 79–84
Johannesson M, Jonsson B, Borgquist L. Willingness to pay for antihypertensive therapy: results of a Swedish pilot study. J Health Econ 1991; 10: 461–74
Neumann PJ, Johannesson M. The willingness to pay for in vitro fertilisation: a pilot study using contingent valuation. Med Care 1994; 32 (7): 686–99
Olsen JA, Donaldson C. Helicopters, hearts and hips: using willingness to pay to set principles for public sector health care programmes. Soc Sci Med 1998; 46 (1): 1–12
Donaldson C, Farrar S, Mapp T, et al. Assessing community values in health care: is the willingness to pay method feasible? Health Care Anal 1997; 5 (1): 7–29
Phillips PR, Russell IT, Jones-Lee MW. The empirical estimation of individual valuation of safety: results of a national sample survey. In: Jones-Lee MW, editor. The economics of safety and physical risk. Oxford: Basil Blackwell, 1989
Little IMD. A critique of welfare economics. London: Clarendon Press, 1957
Mishan EJ. Cost benefit analysis. 4th ed. London: Unwin Hyman, 1988
Boardman AE, Greenberg DH, Vinning AR, et al. Cost-benefit analysis: concepts and practice. New Jersey: Prentice Hall, 1996
O’Brien B, Gafni A. When do the ‘dollars’ make sense? Toward a conceptual framework for contingent valuation studies in health care. Med Decis Making 1996; 16: 288–99
Mitchell RC, Carson RT. Using surveys to value public goods: the contingent valuation method. Washington, DC: Johns Hopkins University Press, 1990
Arrow K, Solow R, Portney P, et al. National Oceanic and Atmospheric Administration (NOAA): report of the NOAA panel on contingent valuation. Fed Regist 1993; 58: 4602
Ryan M, Hughes J. Using conjoint analysis to assess women’s preferences for miscarriage management. Health Econ 1997; 6 (3): 261–73
Ryan M. Conjoint: what’s the point? A Health Economists Study Group meeting. The National University of Ireland; 1933 Jul 13-15; Galway
Boyle KJ, Desvouges WH, Johnson FR, et al. An investigation of part-whole biases in contingent valuation studies. J Environ Econ Manage 1994; 27: 64–83
Ready R, Buzby J, Hu D. Differences between continuous and discrete contingent valuation estimates. Land Econ 1996; 72: 397–411
Brown T, Champ P, Bishop R, et al. Response formats and public good donations. Land Econ 1996; 72: 152–66
Bryan S, Buxton M, Sheldon R, et al. The use of magnetic resonance imaging (MRI) for the investigation of knee injuries: a discrete choice conjoint analysis exercise. Health Economists Study Group Meeting. University of York; 1997 Jul 2-4; York
Propper C. Contingent valuation of time spent on NHS waiting list. Econ J 1991; 100: 193–9
Propper C. The disutility of time spent on the United Kingdom’s National Health Service waiting lists. J Hum Resources 1995; 30: 677–700
Ryan M. Assessing the benefits of health interventions: a role for conjoint analysis? A Labelle Lectureship in Health Service Research. McMaster University; 1997 Oct 16; Hamilton
San Miguel F, Ryan M, McIntosh E. Establishing women’s preferences for the treatment of menorrhagia using the technique of conjoint analysis. Aberdeen: University of Aberdeen, 1997. Health Economics Research Unit discussion paper no.: 06/97
Ryan M. Establishing the convergent validity of willingness to pay and conjoint analysis for eliciting preferences. Health Economists Study Group Meeting. University of Brunel; 1996 Jul 3-5; Brunel
Ryan M, Scott A, Farrar S, et al. Using conjoint analysis in health care: unresolved methodological issues. Aberdeen: University of Aberdeen, 1996. HERU discussion paper no.: 02/96
Ryan M. Using consumer preferences in health care decision making: the application of conjoint analysis. London: Office of Health Economics, 1996
Drummond MF, O’Brien BJ, Stoddart GL, et al. Methods for the economic evaluation of health care. 2nd ed. Oxford: Oxford University Press, 1997
Koopmanschap MA, Rutten FFH, van Ineveld, et al. The friction cost method for measuring indirect costs of disease. J Health Econ 1995; 14: 171–89
Johannesson M, Karlsson G. The friction cost method: a comment. J Health Econ 1997; 16: 249–55
Liljas B. How to calculate indirect costs in economic evaluations. Pharmacoeconomcis 1998; 13: 1–7
Gold MR, Siegel JE, Russell LB, et al. Cost-effectiveness in health and medicine. Oxford: Oxford University Press, 1996
Brouwer WBF, Koopmanschap MA, Rutten FFH. Productivity costs measurement through quality of life? A response to the recommendation of the Washington Panel. Health Econ 1997; 6: 253–9
Koopmanschap MA, Rutten FFH, van Ineveld BM, et al. Reply to Johannesson’s and Karlsson’s comment. J Health Econ 1997; 257-9
Johansson PO. An introduction to modern welfare economics. Cambridge: Cambridge University Press, 1991
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McIntosh, E., Donaldson, C. & Ryan, M. Recent Advances in the Methods of Cost-Benefit Analysis in Healthcare. Pharmacoeconomics 15, 357–367 (1999). https://doi.org/10.2165/00019053-199915040-00003
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DOI: https://doi.org/10.2165/00019053-199915040-00003