Introduction to Health Economics 2


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Introduction to Health Economics 2

  1. 1. INTRODUCTION TO HEALTH ECONOMICS HT4 SO2 Assignment No. 2 University of Glamorgan Enrolment No. 04155084 23 November 2009
  2. 2. Introduction to health Economics. Assignment 2. 04155084 NHS provision of fertility treatment. Background One in six couples may experience problems with their fertility at some point of their fertility lives.1 In UK fertility treatments are tightly regulated by The Human Fertilisation and Embryology Authority (HFEA), a statutory non-departmental Government body that licenses, controls and regulates all aspects related to fertility treatment, including research.2 Fertility treatment came to the public arena in 1978, when in-vitro fertilisation (IVF) was introduced. Since then, thousands of pregnancies have been achieved worldwide using this technique.3 IVF is the most expensive fertility treatment and it is used when other approaches have failed. IVF costs around £ 3,000 privately and it is usual for a woman to need three or more cycles before becoming pregnant. At present, most of the 27,000 IVF treatments a year received by couples are carried out in the private sector. With IVF becoming more and more available, in the last few years there has been a heated debate around fertility treatments. Whether these treatments should be offered free by the NHS or not and if so, how many cycles of treatment should be provided has been points of controversy and fertility treatments have become an important issue for decision makers. In UK, couples with fertility problems have been particularly concerned about ‘postcode prescribing’, by whom some local health authorities (PCTs and LHBs) have been offering fertility treatment while others, sometimes very close geographically, have been denying the same coverage. To try to resolve some of these questions, in late 2000, Alan Milburn, then secretary of state for health asked The National Institute for Clinical Excellence (NICE) to produce guidelines about provision of fertility treatment in the NHS. NICE is an independent NHS organisation created in 1999 to ‘make recommendations on 2
  3. 3. Introduction to health Economics. Assignment 2. 04155084 treatments and care using the best available evidence’. NICE produces cost effectiveness guidelines in three areas of health: technology appraisals, clinical guidelines and interventional procedures.4 It was hoped that NICE was going to produce guidelines based on clinical evidence of effectiveness of the treatments and likely success in men and women of different ages, ending geographical inequality of access and ensuring a consistent approach.5 NICE produced the guidelines in 20046 in conjunction with the National Collaborating Centre for Women’s and Children’s Health (NCCWCH) to address the ‘technical’ aspect of fertility treatment. NICE looked at effectiveness and economic aspects of fertility treatments. The guidelines included the following key recommendations: • ‘Screening all women for chlamydia before they undergo procedures to check if their fallopian tubes are blocked’. • ‘Offering six cycles of intra-uterine insemination (IUI) to couples with: Unexplained fertility problems, or slightly abnormal sperm count, or mild endometriosis’. • ‘Offering three cycles of stimulated IVF to couples in which the woman is aged between 23-39 who have an identified cause of their fertility problems or unexplained fertility of at least three years’.7 The new health secretary, John Reid, welcomed the guidelines saying that the guidelines ‘may lead the way for thousands more women to access infertility treatment’. He also explained that although it was not possible to implement the guidelines straight away the Department of Health wanted to ensure a national level of provision. He also announced that by April 2005 he wanted all PCTs to offer at least one full cycle of treatment to all eligible women and that in the future his department was going to try to implement the full guidelines recommendations.8 Why this issue needs to be addressed from the economic perspective I believe the first decision that needs to be taken regarding fertility treatment is whether the NHS should provide it for free. Whether subfertility is a medical or a 3
  4. 4. Introduction to health Economics. Assignment 2. 04155084 social problem is a question that needs to be answered and a political o even social decision needs to be made based on social values. Some people have said that fertility treatment should not be provided by the NHS at all as it is not a ‘medical necessity’ (not necessary to preserve the patient’s health).9 Moreover, it is an experimental and very extensive treatment and there are other more important priorities that may be undermined by assigning resources to fertility treatments. Other people have replied saying that people with infertility need to be supported. In an interview for the BBC, Professor Alison Murdoch, chairwoman of the British Fertility Society, supported the use of NHS resources and stated that ‘trauma suffered by couples unable to conceive is a legitimate call on NHS resources’.10 Some authors have even suggested that there is a value placed in going though IVF even if this is not successful.11 Once the decision about providing fertility treatment free though the NHS has been taken, the next step is to decide how many resources the NHS should invest on fertility treatment. Resources are scarce and choices are inescapable, fertility treatment will be competing for those NHS scarce resources with other NHS services.12 The way NHS resources are allocated can be decided in different ways, political lobbying, social pressure, a media campaign, pressure from the medical establishment, but by taking the decisions from a health economics point of view we use a framework that allow us to reach conclusions about how these resources can be allocated.13 Health economics uses specific techniques to try to provide a consistent approach about how decisions can be taken. It can be argued that fertility treatment should not be addressed from an economic perspective and doing so is unethical. How can we put a price to a new life? Life has no price and everybody should have the right to free fertility treatment regardless of the cycles needed and the money spent. This argument can be answered from health economics point of view saying that resources in the NHS are finite and resources used to provide fertility treatments will not be used to provide other NHS services (opportunity cost). We have to be aware of the sacrifice that we will do by assigning 4
  5. 5. Introduction to health Economics. Assignment 2. 04155084 resources to fertility treatment.14 What is unethical is to allocate scarce NHS resources without thinking about the consequences and the opportunity foregone that this decision will have on other NHS services. By using health economics we want to try to allocate resources in a fair and equitable way. Health economics can inform policy makers but can also help local PCTs and LHBs in the decision-making process. Health economics can also help deciding which are the extra benefits (marginal benefits) for example of expanding the IVF programme providing more than the three cycles recommended by NICE. The health economists will say that we have to be aware that the costs of IVF increase rapidly because with each cycle in which fertilisation fails, the probability of becoming pregnant declines.15 If we want to expand the programme we have to be aware that this is going to affects other services (opportunity cost). How this issue can be addressed from the economic perspective One of the main challenges when measuring the value of fertility treatment is how it can be measured and compared with other health spending priorities.16 Health economics can provide tools to help comparing different interventions; some of these tools are the methods of economic evaluation. Cost Benefit Analysis (CBA) This economic analysis assigns monetary value to all costs and all benefits of an intervention. The CBA examines whether and objective is worth pursuing (allocative efficiency).14 Tries to answer the question: ‘should we do it?’ ‘Is it worth spending X to get the benefits Y given the opportunity cost?’ CBA is not perfect; it has the difficulty of having to give monetary value to benefits and health consequences. CBA has to use implied values and has to value things that 5
  6. 6. Introduction to health Economics. Assignment 2. 04155084 are intangible like life or death. CBA normally uses market prices when they are available but it has to do some assumptions too.17 CBA can help when addressing the question of whether fertility treatment should be provided. I mentioned that I think that this is a political or even social decision but CBA can help in deciding whether we should assign resources to IVF. It is very important that with the CBA we decide which perspective we are taking: NHS, public sector or society. It is obvious that from a NHS perspective IVF is a very expensive treatment but from a societal perspective it may be worth providing it. Cost Effectiveness Analysis (CEA) This economic analysis is used to compare interventions that are similar, have similar outcomes and therefore can be measured in identical units. With CEA we rank alternative ways to pursue a given objective. CEA does not challenge the decision of whether we should pursue an objective but tries to get the greatest gain for expense analysing whether resources are used efficiently (technical efficiency). CEA addresses the question of ‘how’ should we achieve an objective at the lowest cost or which is the most effective way to achieve this objective.13 CEA has also some weaknesses; for example can not analyse interventions that have several outcomes. CEA generally adopts a health service perspective (lecture notes, M Longo, 2005). CEA can be of a great help when taking decisions about how fertility treatment should be provided. Once the decision about providing fertility treatment has been taken, CEA can help in deciding how we can provide it in the most effective way.18 This is what NICE did with the Guidelines produced in 2004. NICE analysed many aspects and techniques around fertility treatment and made recommendations about how to provide fertility treatment based on their effectiveness and costs. IVF was one of these aspects analysed. For example, based on effectiveness, NICE recommended providing the first three cycles of IVF.6 6
  7. 7. Introduction to health Economics. Assignment 2. 04155084 It is important that we know what we want to achieve when doing a CEA (outcome). In the case of fertility treatment it seems clear that the outcome is pregnancy but authors of CEA should state how they define pregnancy (biochemical pregnancy, clinical pregnancy, ongoing pregnancy, live birth rate, maternity rate, take-home baby rate), if not, direct comparisons with different techniques will be difficult.19 The most cost effective infertility treatment will be the one that achieves pregnancy (with a healthy baby and healthy mother) at a lower cost.20 A technique o programme that can provide fertility treatment for many patients at a very low cost but it is not achieving pregnancy or does not produce healthy babies and mothers is not cost-effective. If we have a programme or treatment that is both more effective in achieving pregnancy and more costly we do not have an answer to the cost effectiveness question but we can show how much extra it will cost to achieve an extra pregnancy (incremental analysis).17 Cost Utility Analysis (CUA) This economic analysis compares interventions that produce different consequences in terms of quantity and quality of life. It is very useful when quality of life is an important outcome. Quality of life can sometimes be a more important outcome than the results of a treatment. CUA uses a multidimensional measure of health called QALY (quality-adjusted-life-year) that allows comparisons across interventions.13 CUA has some problems; technology changes quickly and it is difficult to compare a current study with one done several years ago. CUA has also problems with equity and it is well known that is not fair with the elderly. Despite the fact that NICE usually takes decisions based on QALYs (normally accepts treatments that cost less than £30,000 per QALY) I could not find any single CUA on fertility treatment during my literature review; most of the studies are CEA.18 19 Quality of life must be a very important factor in measuring the outcomes of fertility treatment and I am very surprised this has not been taken into account. I am aware of the fact that the treatments with a higher pregnancy success will attract the higher number of QALYs but it is possible that just the fact of getting fertility treatment could increase the quality of life of the infertile couples. 7
  8. 8. Introduction to health Economics. Assignment 2. 04155084 Bibliography Word Count: 1,985 (excluding bibliography) 8