Journal of Child Psychology and Psychiatry 55:6 (2014), pp 733–735
doi:10.1111/jcpp.12264
Commentary: Do clinicians need health economics? – a commentary on Beecham (2014) Eric Taylor King’s College London Institute of Psychiatry, London, UK
Decisions in conditions of scarcity Translation from scientific knowledge into clinical practice is a complex process. It is not enough to know what is effective: what is affordable and achievable matters too. Setting priorities is a tricky business, and health economics seeks to acquire the scientific knowledge that can guide those who must set them. Health economists, however, have in the past given little attention to the problems of child and adolescent mental health (CAMH). Beecham’s article in this issue is a very helpful review of the state of the art. Studies are still few, but they are increasing, and her account shows how a useful methodology is developing. It gives a thorough description of economic studies on child mental health disorders; and shows how they can provide information needed for planning what should be provided. The review will be relevant to all practitioners who are interested in funding, equity and allocation – and most will be. First, many clinicians will have management responsibilities for a child mental health service, and help to decide what procedures are justified in situations of scarcity. Second, and even if they do not make those decisions themselves, their practice will be strongly influenced by the guidelines of commissioners of a publicly funded service or insurers of managed care. Different tariffs for different clinical presentations are just one topical example of how economic thinking will influence practitioners’ work. Third, most clinicians will recognise, at least in theory, the need to consider what is affordable as well as what works. Many will feel they owe some duty of care to the community as well, and will consider the balance between intensive treatment for a few and less expensive treatment for many. Doctors are the traditional setters of priorities in health provision. Many clinicians, none the less, have profound reservations about decisions comparing the needs of one group of patients with another. They wish to respond effectively to the needs of their patients, not to the wider considerations of how to ration. Such attitudes export the decision making to agencies such as local authorities, elected parliaments or unelected commissioning boards.
This decision making is painful and difficult; and especially so when resources are shrinking. Professional opinion about best practice is often embedded in ‘guidelines’ documents or in textbooks which are influential internationally. Such writings, however, seldom include economic arguments; indeed, it is hard to see how they could effectively do so on an international basis. Costs and values differ greatly between societies. The evidence base for therapies is then taken as sufficient grounds for recommendations about priorities, with the risk that resources are allocated in an inefficient or inequitable way.
Rationing The demand for mental health services exceeds supply everywhere, and perhaps always will. In the face of this, clinicians sometimes find economic analysis to be a utopian discourse. It is in the sense that it relates to rational planning and balancing of costs and outcomes. In practice, many other considerations come into play (Robinson, 1999). In a famous example, Maynard (1991) described the cost, per quality-adjusted life year, of neurosurgery for malignant brain tumours to be a hundred times as great as the similar figure for aortic valve surgery. The result was not an abolition of tumour neurosurgery. The economic analyses should be seen as guides for thought about what should be provided, not in themselves a practicable set of determinants.
Who decides? Ideally, rationing systems would be transparent and open to democratic debate. There are, however, major traps in the way of an elected politician who stumbles into the arena. Powerful media figures and eloquent lobbying groups are waiting to pounce. No wonder that politicians may prefer to export decisions to a technical level, to find a discourse that is impersonal and technical, and to obscure personal responsibility for the consequences of decisions. If rationing is delegated to insurance companies or to boards of health commissioners, their priorities may well be limited to the allocation of their own budgets rather than to welfare expenditure as a
© 2014 The Author. Journal of Child Psychology and Psychiatry. © 2014 Association for Child and Adolescent Mental Health. Published by John Wiley & Sons Ltd, 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main St, Malden, MA 02148, USA
734
Eric Taylor
whole. If society as a whole is brought in – through referenda, or citizen juries, or representative focus groups – then the problem becomes that of the ‘ignorant consumer’. Health literacy is not universal and many will not have the knowledge to make good judgements about what will work best. There may be a downgrading of resource provision for those sections with which most people do not identify: the intellectually disabled, the poor, the aged and – unfortunately for readers of this journal – the mentally ill. The state of Oregon pioneered the use of collective priorities; its evaluation indicated a strong favouring of ‘rescue’ measures – the immediate needs for treatment of life-threatening problems (Hadorn, 1991).
The example of NICE The National Health Service of the UK set up a special authority for advice on new technologies, developing guidelines and improving quality. It is now called the National Institute for Health and Clinical Excellence (NICE), and is widely regarded as providing an international lead for publicly funded services. One of the controversial aspects of its practice is the use of QALYs (quality-adjusted life years saved) as the outcome against which to judge the relative cost of different types of health intervention. Other considerations do come into it sometimes – as when they recommended an intervention for motor neurone disease that came in above the limit of £30,000 per QALY, on grounds of the severity of the condition, the high value attached by patients to tracheostomy-free survival, and their relatively short expected life span. In general, however, they seek to recommend only treatments whose cost per QALY is less than £20-30,000 (up to €36,000, $ 50,000). Schlander (2008) gives an economist’s critique of their cost–utility approach. He advocates a ‘reflective equilibrium’ approach for the social acceptability of rankings. Moral judgements about social desirability of interventions would then play a greater part, for example in whether the treatment of ADHD with medication should have a lower priority than the relationship-based treatment of attention disorders. The making of consensus remains a problem. There is justice in an institutional approach such as that of NICE, if it can involve transparency to the public, relevance to scientific evidence, openness to revisions and appeal, and enforceability. Puzzles, however, remain in how to quantify both costs and outcomes.
Quantifying costs How much should society be willing to pay for an effective intervention to promote child and adolescent mental health? One answer would be ‘the same as for any comparably effective treatment in medicine’. The issue would still remain of how to attain comparability; and therefore, indirectly, how to allocate resources to CAMH.
J Child Psychol Psychiatr 2014; 55(6): 733–5
Braithwaite, Meltzer, King, Leslie, and Roberts (2008) contrasted the widespread US recommendation, for an upper limit of about $50,000 (€36,000, £30,000) per QALY, with an estimated cost-effectiveness rule that was derived from considering the incremental advances of modern medicine and the costs and benefits of unsubsidised health insurance. Their estimate worked out at a much higher figure for societal willingness to pay: between $109,000 (€79,000, £66,000) and $297,000 (€215,000, £180,000) per QALY saved. In similar vein, Towse (2009) argued that the NICE limit was too low, and society was willing to pay more for its health. An estimate of society’s willingness to pay, however, may have little to do with the willingness of real-world commissioners – in insurance or publicly funded systems – who actually pay the piper. The quantitative estimate of costs does not have a standard methodology. Beecham’s article emphasises some of the difficulties in comparing between estimates. Should one include only costs to the health budget, or the wider, and usually much greater, costs of education, justice, social care and family burden? It is perhaps unrealistic to expect health to bear all its costs if the savings accrue to very different agencies and budgets. For instance, an effective drug to enhance reading (which might well be introduced) could be a cost to health services for treating dyslexia, but have complex implications for education, some of them (such as savings on remedial teachers) probably unwelcome. Fair and efficient means of allocating budgets, setting tariffs, or cross-charging between agencies might approach more closely to the ideal of rational allocation of resource.
Quantifying outcomes Many of the studies reviewed by Beecham aim at cost–utility analysis, to relate costs not only to the savings for health and other budgets but also to achievement of desirable outcomes. Economic models such as those of NICE seek to inform senior management levels about which interventions are more or less valuable. One consequence is that the key outcome chosen – the QALY – has to be applicable across the whole field of medicine. There are doubts for child mental health about whether that achieves a fair comparison between physical and mental health; and whether it adequately addresses long-term risks. Furthermore, the QALY is not necessarily a sensitive index for specific disorders. Those who draw up guidelines for conditions as different as autism, ADHD, depression and eating disorders should be able to compare the value of interventions for each on the basis of outcome measures that are directly relevant to the particular condition even if they do not figure in the overall measurement of quality of life. Better means of quantifying value in terms of impairment of function
© 2014 The Author. Journal of Child Psychology and Psychiatry. © 2014 Association for Child and Adolescent Mental Health.
735
doi:10.1111/jcpp.12264
Commentary: Do clinicians need health economics?
and distress are sorely needed for the development of guidelines about what ought to be provided for particular conditions.
Methodology of studies varies considerably, and results often vary too. Nevertheless, they have the great virtue of making explicit the complexities of service choices. Beecham’s review is not only for economists and researchers: clinicians need not only the lessons from the studies reviewed but more and better research.
Values Money is not a perfect way of valuing, but it has the merit of clarity. There is, after all, no single answer about how resource should be distributed in a just society. Should one pay premiums for a very severe disorder? Or for the effectiveness of the intervention? Or for benefit to disadvantaged sections of the community? Or for the economic value of sufferers to the community, and the expected benefit to the national economy? Or should the market decide, with a greater benefit for those who are able to pay more, or informed enough to make good personal decisions? Should one cost (and thence set tariffs) on the basis of what is currently provided, or on the basis of what would constitute high-quality care? When professionals increase their recognition of disorders (as is happening for autism and ADHD in many countries), should funding automatically increase? Perhaps the complex processes of lobbying and negotiation which now prevail are the best that can be done to integrate different perspectives in a democratic society. Certainly decision-making will be done in different ways in different countries. Low- and middle-income countries have exceptionally difficult choices to make and economic costing of alternatives will be crucial for them. In all countries, the attitudes and beliefs of the people who make priority decisions will be crucial. This too is the stuff of health economics, and we can hope to see more research into how it works.
Summary Clinical and educational professionals are increasingly involved in debates about priorities. Economic science is extending its ability to help us understand the true costs of our services and to decide, or advise, between alternatives in provision.
Acknowledgements This commentary article was invited by the JCPP Editor-in-Chief and has been subject to internal review. The author has served as an expert for NICE and chaired the NICE guidelines development group for ADHD, but has declared that he has no competing or potential conflicts of interest in relation to this article.
Correspondence Eric Taylor, King’s College London Institute of Psychiatry, De Crespigny Park, London SE5 8AF, UK; Email: [email protected]
References Beecham, J. (2014). Annual Research Review: Child and adolescent mental health interventions: a review of progress in economic studies across different disorders. Journal of Child Psychology and Psychiatry, 55, 714–732. Braithwaite, R.S., Meltzer, D.O., King, J.T. Jr, Leslie, D., & Roberts, M.S. (2008). What does the value of modern medicine say about the $50,000 per quality-adjusted life-year decision rule? Medical Care, 46, 349–356. Hadorn, D.C. (1991). Setting health care priorities in Oregon. Cost-effectiveness meets the rule of rescue. Journal of the American Medical Association, 265, 2218–2225. Maynard, A. (1991). Developing the health care market. The Economic Journal, 101, 1277–1286. Robinson, R. (1999). Limits to rationality: economics, economists and priority setting. Health Policy, 49, 13–26. Schlander, M. (2008). The use of cost-effectiveness by the National Institute for Health and Clinical Excellence (NICE): no (t yet an) exemplar of a deliberative process. Journal of Medical Ethics, 34, 534–539. Towse, A. (2009). Should NICE’s threshold range for cost per QALY be raised? Yes. BMJ, 338, b181.
Accepted for publication: 28 March 2014
© 2014 The Author. Journal of Child Psychology and Psychiatry. © 2014 Association for Child and Adolescent Mental Health.
doi:10.1111/jcpp.12264
Commentary: Do clinicians need health economics? – a commentary on Beecham (2014) Eric Taylor King’s College London Institute of Psychiatry, London, UK
Decisions in conditions of scarcity Translation from scientific knowledge into clinical practice is a complex process. It is not enough to know what is effective: what is affordable and achievable matters too. Setting priorities is a tricky business, and health economics seeks to acquire the scientific knowledge that can guide those who must set them. Health economists, however, have in the past given little attention to the problems of child and adolescent mental health (CAMH). Beecham’s article in this issue is a very helpful review of the state of the art. Studies are still few, but they are increasing, and her account shows how a useful methodology is developing. It gives a thorough description of economic studies on child mental health disorders; and shows how they can provide information needed for planning what should be provided. The review will be relevant to all practitioners who are interested in funding, equity and allocation – and most will be. First, many clinicians will have management responsibilities for a child mental health service, and help to decide what procedures are justified in situations of scarcity. Second, and even if they do not make those decisions themselves, their practice will be strongly influenced by the guidelines of commissioners of a publicly funded service or insurers of managed care. Different tariffs for different clinical presentations are just one topical example of how economic thinking will influence practitioners’ work. Third, most clinicians will recognise, at least in theory, the need to consider what is affordable as well as what works. Many will feel they owe some duty of care to the community as well, and will consider the balance between intensive treatment for a few and less expensive treatment for many. Doctors are the traditional setters of priorities in health provision. Many clinicians, none the less, have profound reservations about decisions comparing the needs of one group of patients with another. They wish to respond effectively to the needs of their patients, not to the wider considerations of how to ration. Such attitudes export the decision making to agencies such as local authorities, elected parliaments or unelected commissioning boards.
This decision making is painful and difficult; and especially so when resources are shrinking. Professional opinion about best practice is often embedded in ‘guidelines’ documents or in textbooks which are influential internationally. Such writings, however, seldom include economic arguments; indeed, it is hard to see how they could effectively do so on an international basis. Costs and values differ greatly between societies. The evidence base for therapies is then taken as sufficient grounds for recommendations about priorities, with the risk that resources are allocated in an inefficient or inequitable way.
Rationing The demand for mental health services exceeds supply everywhere, and perhaps always will. In the face of this, clinicians sometimes find economic analysis to be a utopian discourse. It is in the sense that it relates to rational planning and balancing of costs and outcomes. In practice, many other considerations come into play (Robinson, 1999). In a famous example, Maynard (1991) described the cost, per quality-adjusted life year, of neurosurgery for malignant brain tumours to be a hundred times as great as the similar figure for aortic valve surgery. The result was not an abolition of tumour neurosurgery. The economic analyses should be seen as guides for thought about what should be provided, not in themselves a practicable set of determinants.
Who decides? Ideally, rationing systems would be transparent and open to democratic debate. There are, however, major traps in the way of an elected politician who stumbles into the arena. Powerful media figures and eloquent lobbying groups are waiting to pounce. No wonder that politicians may prefer to export decisions to a technical level, to find a discourse that is impersonal and technical, and to obscure personal responsibility for the consequences of decisions. If rationing is delegated to insurance companies or to boards of health commissioners, their priorities may well be limited to the allocation of their own budgets rather than to welfare expenditure as a
© 2014 The Author. Journal of Child Psychology and Psychiatry. © 2014 Association for Child and Adolescent Mental Health. Published by John Wiley & Sons Ltd, 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main St, Malden, MA 02148, USA
734
Eric Taylor
whole. If society as a whole is brought in – through referenda, or citizen juries, or representative focus groups – then the problem becomes that of the ‘ignorant consumer’. Health literacy is not universal and many will not have the knowledge to make good judgements about what will work best. There may be a downgrading of resource provision for those sections with which most people do not identify: the intellectually disabled, the poor, the aged and – unfortunately for readers of this journal – the mentally ill. The state of Oregon pioneered the use of collective priorities; its evaluation indicated a strong favouring of ‘rescue’ measures – the immediate needs for treatment of life-threatening problems (Hadorn, 1991).
The example of NICE The National Health Service of the UK set up a special authority for advice on new technologies, developing guidelines and improving quality. It is now called the National Institute for Health and Clinical Excellence (NICE), and is widely regarded as providing an international lead for publicly funded services. One of the controversial aspects of its practice is the use of QALYs (quality-adjusted life years saved) as the outcome against which to judge the relative cost of different types of health intervention. Other considerations do come into it sometimes – as when they recommended an intervention for motor neurone disease that came in above the limit of £30,000 per QALY, on grounds of the severity of the condition, the high value attached by patients to tracheostomy-free survival, and their relatively short expected life span. In general, however, they seek to recommend only treatments whose cost per QALY is less than £20-30,000 (up to €36,000, $ 50,000). Schlander (2008) gives an economist’s critique of their cost–utility approach. He advocates a ‘reflective equilibrium’ approach for the social acceptability of rankings. Moral judgements about social desirability of interventions would then play a greater part, for example in whether the treatment of ADHD with medication should have a lower priority than the relationship-based treatment of attention disorders. The making of consensus remains a problem. There is justice in an institutional approach such as that of NICE, if it can involve transparency to the public, relevance to scientific evidence, openness to revisions and appeal, and enforceability. Puzzles, however, remain in how to quantify both costs and outcomes.
Quantifying costs How much should society be willing to pay for an effective intervention to promote child and adolescent mental health? One answer would be ‘the same as for any comparably effective treatment in medicine’. The issue would still remain of how to attain comparability; and therefore, indirectly, how to allocate resources to CAMH.
J Child Psychol Psychiatr 2014; 55(6): 733–5
Braithwaite, Meltzer, King, Leslie, and Roberts (2008) contrasted the widespread US recommendation, for an upper limit of about $50,000 (€36,000, £30,000) per QALY, with an estimated cost-effectiveness rule that was derived from considering the incremental advances of modern medicine and the costs and benefits of unsubsidised health insurance. Their estimate worked out at a much higher figure for societal willingness to pay: between $109,000 (€79,000, £66,000) and $297,000 (€215,000, £180,000) per QALY saved. In similar vein, Towse (2009) argued that the NICE limit was too low, and society was willing to pay more for its health. An estimate of society’s willingness to pay, however, may have little to do with the willingness of real-world commissioners – in insurance or publicly funded systems – who actually pay the piper. The quantitative estimate of costs does not have a standard methodology. Beecham’s article emphasises some of the difficulties in comparing between estimates. Should one include only costs to the health budget, or the wider, and usually much greater, costs of education, justice, social care and family burden? It is perhaps unrealistic to expect health to bear all its costs if the savings accrue to very different agencies and budgets. For instance, an effective drug to enhance reading (which might well be introduced) could be a cost to health services for treating dyslexia, but have complex implications for education, some of them (such as savings on remedial teachers) probably unwelcome. Fair and efficient means of allocating budgets, setting tariffs, or cross-charging between agencies might approach more closely to the ideal of rational allocation of resource.
Quantifying outcomes Many of the studies reviewed by Beecham aim at cost–utility analysis, to relate costs not only to the savings for health and other budgets but also to achievement of desirable outcomes. Economic models such as those of NICE seek to inform senior management levels about which interventions are more or less valuable. One consequence is that the key outcome chosen – the QALY – has to be applicable across the whole field of medicine. There are doubts for child mental health about whether that achieves a fair comparison between physical and mental health; and whether it adequately addresses long-term risks. Furthermore, the QALY is not necessarily a sensitive index for specific disorders. Those who draw up guidelines for conditions as different as autism, ADHD, depression and eating disorders should be able to compare the value of interventions for each on the basis of outcome measures that are directly relevant to the particular condition even if they do not figure in the overall measurement of quality of life. Better means of quantifying value in terms of impairment of function
© 2014 The Author. Journal of Child Psychology and Psychiatry. © 2014 Association for Child and Adolescent Mental Health.
735
doi:10.1111/jcpp.12264
Commentary: Do clinicians need health economics?
and distress are sorely needed for the development of guidelines about what ought to be provided for particular conditions.
Methodology of studies varies considerably, and results often vary too. Nevertheless, they have the great virtue of making explicit the complexities of service choices. Beecham’s review is not only for economists and researchers: clinicians need not only the lessons from the studies reviewed but more and better research.
Values Money is not a perfect way of valuing, but it has the merit of clarity. There is, after all, no single answer about how resource should be distributed in a just society. Should one pay premiums for a very severe disorder? Or for the effectiveness of the intervention? Or for benefit to disadvantaged sections of the community? Or for the economic value of sufferers to the community, and the expected benefit to the national economy? Or should the market decide, with a greater benefit for those who are able to pay more, or informed enough to make good personal decisions? Should one cost (and thence set tariffs) on the basis of what is currently provided, or on the basis of what would constitute high-quality care? When professionals increase their recognition of disorders (as is happening for autism and ADHD in many countries), should funding automatically increase? Perhaps the complex processes of lobbying and negotiation which now prevail are the best that can be done to integrate different perspectives in a democratic society. Certainly decision-making will be done in different ways in different countries. Low- and middle-income countries have exceptionally difficult choices to make and economic costing of alternatives will be crucial for them. In all countries, the attitudes and beliefs of the people who make priority decisions will be crucial. This too is the stuff of health economics, and we can hope to see more research into how it works.
Summary Clinical and educational professionals are increasingly involved in debates about priorities. Economic science is extending its ability to help us understand the true costs of our services and to decide, or advise, between alternatives in provision.
Acknowledgements This commentary article was invited by the JCPP Editor-in-Chief and has been subject to internal review. The author has served as an expert for NICE and chaired the NICE guidelines development group for ADHD, but has declared that he has no competing or potential conflicts of interest in relation to this article.
Correspondence Eric Taylor, King’s College London Institute of Psychiatry, De Crespigny Park, London SE5 8AF, UK; Email: [email protected]
References Beecham, J. (2014). Annual Research Review: Child and adolescent mental health interventions: a review of progress in economic studies across different disorders. Journal of Child Psychology and Psychiatry, 55, 714–732. Braithwaite, R.S., Meltzer, D.O., King, J.T. Jr, Leslie, D., & Roberts, M.S. (2008). What does the value of modern medicine say about the $50,000 per quality-adjusted life-year decision rule? Medical Care, 46, 349–356. Hadorn, D.C. (1991). Setting health care priorities in Oregon. Cost-effectiveness meets the rule of rescue. Journal of the American Medical Association, 265, 2218–2225. Maynard, A. (1991). Developing the health care market. The Economic Journal, 101, 1277–1286. Robinson, R. (1999). Limits to rationality: economics, economists and priority setting. Health Policy, 49, 13–26. Schlander, M. (2008). The use of cost-effectiveness by the National Institute for Health and Clinical Excellence (NICE): no (t yet an) exemplar of a deliberative process. Journal of Medical Ethics, 34, 534–539. Towse, A. (2009). Should NICE’s threshold range for cost per QALY be raised? Yes. BMJ, 338, b181.
Accepted for publication: 28 March 2014
© 2014 The Author. Journal of Child Psychology and Psychiatry. © 2014 Association for Child and Adolescent Mental Health.
