The need for a new framework for the economic evaluation of health services in a national health scheme

Jeff R. Richardson, John McKie, Kompal Sinha
DOI: 10.4236/health.2010.29165                

Abstract

The normative theory of economic evaluation and its welfare theoretic basis are deeply problematical and result in recommendations which are potentially unfair. The root cause of the problem is the set of assumptions behind the theory which posit behaviours and motivations that are not universal, and which exclude other behaviours and motivations that are potentially important. As falsification of assumptions may be evaded indefinitely this paper presents an alternative critique. We commence with six an- omalies with the theory which are attributable to the assumptions. The first three—the net present value criterion, the willingness to pay criterion and moral hazard—arise from welfare theory. The remaining three are associated with the present definition of cost, the concept of efficiency and the omission of sharing, which are common to most economic evaluation. We argue that these anomalies are indicative of a defective core theory and that they are equivalent to observations that conflict with a positive theory. In the final section we outline and illustrate a more general framework for decision making that is capable of overcoming the ano- malies we discuss.

Keywords

Economic Evaluation; Economic Costs; Welfare Theory; Empirical Ethics; Cost Benefit Analysis

Conflicts of Interest

The authors declare no conflicts of interest.

References

[1]	Mandelbrot, B.B. (1997) Fractals and scaling in finance. Springer, New York.
[2]	Skidelsky, A. (2009) Keynes: The return of the master. Allen Lane, London.
[3]	Robbins, L. (1938) An essay on the nature and significance of economic science. 2nd Edition, MacMillan, London.
[4]	Samuelson, P.A. (1938) A note on the pure theory of consumer behaviour. Economica, 5(17), 61-71.
[5]	Birch, S. and Donaldson, C. (2003) Valuing the benefits and costs of health care programmes: Where’s the ‘extra’ in extra-welfarism? Social Science & Medicine, 56(5), 1121-1133.
[6]	Mason, H., Jones-Lee, M. and Donaldson, C. (2009) Modelling the monetary value of a QALY: A new approach based on UK data. Health Economics, 18(8), 933- 950.
[7]	Culyer, A. (1989) The normative economics of health care finance and provision. Oxford Review of Economic Policy, 5(1), 34-58.
[8]	Garber, A.M. and Phelps, C.E. (1997) Economic foundations of cost-effectiveness analysis. Journal of Health Economics, 16(1), 1-31.
[9]	Sen, A. (2009) The idea of justice. Allen Lane, London.
[10]	Shiroiwa, T., Yoon-Kyoung, S., Takashi, F., Hui-Chu, L., Sang-Cheol, B. and Tsutani, K. (2010) International survey on willingness to pay (WTP) for one additional QALY gained: What is the threshold of cost effectiveness. Health Economics, 19(5), 422-437.
[11]	Richardson, J. and Smith, R.D. (2004) Calculating society’s willingness to pay for a QALY: Key questions for discussion. Applied Health Economics and Health Policy, 3(3), 125-126.
[12]	Smith, R.D. and Richardson, J. (2005) Can we estimate the ‘social’ value of a QALY: Four core issues to resolve. Health Policy, 74(1), 77-84.
[13]	Pauly, M.V. (1968) The economics of moral hazard: Comment. American Economic Review, 58(1), 531-537.
[14]	Richardson, J. and Pope, R. (2009) The invalidity of expected utility theory and its misuse in the economic evaluation of health and safety. In: Schlander, M., Ed., Economic Evaluation of Health Care Programs: Current Concept, Controversies and International Experience, Springer, New York.
[15]	Richardson, J. and McKie, J. (2007) Economic evaluation of services for a national health scheme: The case for a fairness based framework. Journal of Health Economics, 26(4), 785-799.
[16]	Orwell, G. (1949) Nineteen eighty-four. Harcourt, Brace and Co, New York.
[17]	Mooney, G. (2005) Communitarian claims and community capabilities: Furthering priority setting? Social Science & Medicine, 60(2), 247-255.
[18]	Mooney, G. (2009) Challenging Health Economics. Oxford University Press, Oxford.
[19]	Fehr, E. and Schmidt, K.M. (1999) A theory of fairness, competition and cooperation. The Quarterly Journal of Economics, 114(3), 817-868.
[20]	Forsythe, R., Horowitz, J.L., Savin, N.E. and Sefton, M. (1994) Fairness in simple bargaining experiments. Games and Economic Behavior, 6(3), 347-369.
[21]	Kagel, J.H., Kim, C. and Moser, D. (1996) Fairness in ultimatum games with asymmetric information and asymmetric payoffs. Games and Economic Behavior, 31(1), 100-110.
[22]	Kahneman, D., Knetsch, J.L. and Thaler, R.H. (1986) Fairness and the assumption of economics. The Journal of Business, 59(4), S285-S300.
[23]	Culyer, A. (1990) Commodities, characteristics of commodities, characteristics of people, utilities and quality of life. In: Baldwin, S., Godfrey, C. and Propper, C., Eds., Quality of Life: Perspective and Policies, Routledge, London.
[24]	Beinhocker, E. (2007) The origin of wealth: Evolution, complexity, and the radical remaking of economics. Random House, Milsons Point.
[25]	Gintis, H., Bowles, S., Boyd, R. and Fehr, R. (2005) Moral sentiments and material interests: the foundations of cooperation in economic life. Massachusetts Institute of Technology Press, Cambridge.
[26]	Lehrer, J. (2009) The decisive moment: How the brain makes up its mind. Edinburgh Canongate Books.
[27]	Andreoni, J. (1989) Giving with impure altruism: Applications to charities and ricardian equivalence. The Journal of Political Economy, 97(6), 1447-1458.
[28]	Andreoni, J. (1990) Impure altruism and donations to public goods: A theory of warm glow giving. Economic Journal, 100(401), 464-477.
[29]	Rice, T. (1998) The economics of health reconsidered. Health Administration Press, Chicago, Illinois.
[30]	Richardson, J., McKie, J., Sinha, K. (2010) A critique of efficiency focussed economic evaluation in the context of a NHS: The case for empirical ethics. In: Schlander, M., Ed., Economic Evaluation of Health Care Programs: Current Concepts Controversies and International Experience, Springer, New York.
[31]	Weinstein, M.C., Stason, W.B. (1977) Foundations of cost-effectiveness analysis for health analysis and medical practices. New England Journal of Medicine, 296(13), 716-721.
[32]	Richardson, J., McKie, J. and Sinha, K. (2009) A critique of efficiency focussed economic evaluation in the context of a nhs: The case for empirical ethics. Centre for Health Economics, Monash University, Melbourne.
[33]	Schlander, M. (2007) Health technology assessments by the national institute for health and clinical excellence: A qualitative study (innovation and valuation in health care). Springer, London.
[34]	Coast, J., Smith, R.D. and Lorgelly, P. (2008) Welfarism, extra welfarism and capability: The spread of ideas in health economics. Social Science & Medicine, 67(7), 1190-1198.
[35]	Brouwer, W., Culyer, A., Job, N., van Exel, A. and Rutten, F.F. (2008) Welfarism vs extra welfarism. Journal of Health Economics, 27(2), 325-338.
[36]	Richardson, J. and McKie, J. (2009) The impossibility of an ideal metric for health service benefit measurement. Centre for Health Economics, Monash University, Melbourne.
[37]	Richardson, J., Sinha, K. and Iezzi, A. (2009) Why we should not minimise cost per QALY: Theoretical and empirical evidence. Centre for Health Economics, Monash University, Melbourne.
[38]	Richardson, J. and McKie, J. (2005) Empiricism, ethics and orthodox economic theory: What is the appropriate basis for decision making in the health sector. Social Science & Medicine, 60(2), 265-275.
[39]	Von Winterfeldt, D. and Edwards, W. (1986) Decision analysis and behavioral research. Cambridge University Press, Cambridge.
[40]	Feeny, D., Furlong, W., Torrance, G., Goldsmith, C., Zhu, Z., DePaw, S., et al. (2002) Multiattribute and single-attr- ibute utility functions for the Health Utility Index Mark 3 system. Medical Care, 40(2), 113-128.
[41]	Feeny, D.H., Torrance, G.W. and Furlong, W.J. (1996) Health utilities index. In: Spilker, B., Ed., Quality of Life and Pharmacoeconomucs in Clinical Trials, Lippincott-Raven Publishers, Philidelphia.
[42]	Burgess, L., Street, D.J., Viney, R. and Louviere, J. (2007) Design of hoice experiments in health economics. The Elgar Companion to Health Economics. Edward Elgar, Cheltenham.
[43]	Popper, K. (1959) The logic of scientific discovery. Hutchinson, London.
[44]	Richardson, J., McKie, J. and Sinha, K. (2009) A critique of efficiency-focused economic evaluation in the context of a NHS: The case for empirical ethics. In: Schlander, M., Ed., Economic Evaluation of Health Care Programs: Current Concepts Controversies and International Experience, Springer, New York.