Costs and Benefits in Health Care and Prevention: An International Approach to Priorities in Medicine PDF
Preview Costs and Benefits in Health Care and Prevention: An International Approach to Priorities in Medicine
U. Laaser E. 1. Roccella 1. B. Rosenfeld H. Wenzel (Eds.) Costs and Benefits in Health Care and Prevention An International Approach to Priorities in Medicine With 13 Figures and 43 Tables Springer-Verlag Berlin Heidelberg New York London Paris Tokyo Hong Kong Barcelona Prof. Dr. med. U. Laaser Universitiit Bielefeld und Institut fUr Dokumentation und Information, Sozialmedizin und 6ffentliches Gesundheitswesen (lOIS) Westerfeldstr. 35-37, 0-4800 Bielefeld Federal Republic of Germany E.1.Roccella, Ph.D. National Institutes of Health, National Heart, Lung, and Blood Institute Building 31, Room 4, 16C, Bethesda, Maryland 20892, USA Prof. 1. B. Rosenfeld University of Tel Aviv, Belinson Medical Center Petah Tikva 49 100, Israel H.Wenzel Boehringer Mannheim GmbH, Abteilung G-K Postfach 310120, 0-6800 Mannheim 31 Federal Republic of Germany ISBN -13: 978-3-540-52708-4 e-ISBN -13: 978-3-642-75781-5 DOl: 10.10071978-3-642-75781-5 This work is subject to copyright. All rights are reserved, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in other ways, and storage in data banks. Duplication of this publication or parts thereof is only permitted under the provisions of the German Copyright Law of September 9,1965, in its current version, and a copyright fee must always be paid. Violations fall under the prosecution act of the German Copyright Law. © Springer-Verlag Berlin Heidelberg 1990 The use of registered names, trademarks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. Product Liability: The publisher can give no guarentee for information about drug dosage and application thereof contained in this book. In every individual case the respective user must check its accuracy by consulting other pharmaceutical literature. 2119/3140543210 -Printed on acid-free paper Proceedings of a Conference on the Analysis of Costs and Benefits in Health Care, Bielefeld, June 17th and 18th, 1988. Organized under the auspices of: German Society for Social Medicine and Prevention (DGSMP), and German Society for Medical Documentation, Informatics and Statistics (GMDS), Working Group on Epide miology Faculty of Social Sciences, University of Bielefeld, FRG Institute for Documentation and Information, Social Medicine and Public Health (IDIS), Bielefeld, FRG National Heart, Lung, and Blood Institute (NHLBI), Bethesda Md., USA Tel Aviv University, Sackler School of Medicine, Beilinson Medical Center, Petah Tikva, Israel World Health Organization (WHO), Copenhagen In cooperation with Boehringer Mannheim GmbH v Motive A pragmatic compromise has to be worked out between years of life and quality of life. The guiding principles are respect for other people, beneficience, justice, information, and a systematic assessment of risks and benefits. Geoffrey Rose Lancet 1987 VI Preface of the Editors Nowadays costs are undoubtedly a key issue in the further development of modern health care systems. This implies an often painful socio-political process in making decisions between almost equally important alternatives, as the enormous financial means required are restricted everywhere. The fitting together in models of efforts and related effects and their most preponderant determinants provides for one of the core purposes of the analysis of costs and benefits, namely the definition of rational priorities in health care. So far the prevailing notion was that international comparisons of costs and benefits are very difficult to say the least or rather impossible to admit the truth. Our impression, ho wever, is that two more recent developments might be capable to change this pessimi stic view. One concerns the availability of very comprehensive epidemiological data on the actual distribution of mass diseases in our populations and on the future risks associated with their precursors or risk-factors. Thus, at least in the cardiovascular area, the publication of the Pooling-Project(l) and of the big intervention studies in recent years(2) have put us into a position, where we can estimate life expectation and years of life gained in populations with astonishing precision by the determination of risk-factor changes alone. Up to date this has not been realized by health economists to its full extent. The other development is constituted by the methodological improvements in the measurement of the quality oflife. We are by now in a state, where we can proceed from a crude human capital approach to the valuation of a quite differentiated set of qualities of human life well beyond the age of retirement. Techniques became feasible to deter mine a willingness to pay for specified improvements of the quality of life. It might well be the first time that the increasingly important theme of costs and benefits in health care is discussed between three highly developed but quite different countries: The Federal Republic of Germany, Israel and the United States. The scientific coopera tion between the editors -established over many years in the framework of the German American, American.Israeli-and Israeli-German-Research-Programs -laid the ground for this endeavour which could be realized at a threelateral conference on this topic in BielefeldlFRG, June 17 and 18, 1988, organized by the Northrhine-Westphalian Insti tute for Documentation and Information, Social Medicine and Public Health (IDIS). This conference might have been also one of the few events, where clinicians, epidemiologists and economists got the occasion to exchange their views and put together a more complete picture of these complex issues. In order to somewhat reduce complexity, however, concentration ensued on cardiovascular diseases and upon one of VII the primary risk-factors, i.e. hypertension, where today we can also draw on the most advanced epidemiological data-bases. Of course high blood pressure by no means is the only suitable subject for cost-benefit-analysis. Even more the epidemiological concept of cardiovascular risk-factors should provide a fruitful model for other diseases. Bielefeld, Bethesda, Tel Aviv, Mannheim January 1990 U. Laaser, E.J. Roccella, J.B. Rosenfeld, H. Wenzel References (1) The Pooling Project Research Group: Relationship of blood pressure, serum cholesterol, smoking habit, relative weight and ECG abnormalities to incidence of major coronary events. J. Chron. Dis. 31 (1978),201-306 (2) Laaser, U., A1lhoff, P.: Cardiovascular intervention studies, problems, and perspectives. In: Primary Hypertension, ed. W. Kaufmann. Springer Co., Berlin, Heidelberg, New York (1985),145-151 VIII Preamble If money would not matter, health care would still have its price. Patients would still un dergo drug treatment at the "cost" of side-effects, and a decrease in tobacco production as a consequence of successful health education would still "cost" agriCUlture the effort to produce alternative crops. However, money does matter. It matters both in capitalist and in socialist economies; it matters in affluent societies and, all too often and to a devastating degree, in developing countries. Money matters so much that the medical community is often apt to neglect the biological, social or environmental costs of health intervention. It is therefore gratifying that the last chapter of this book is devoted to the "New Dimension: Quality of Life". Naturally, the main issue in the present book is money, the universal system of measuring material values. It is both useful and interesting to compute the costs of various health care components in terms of financial expenditure; such exercise confers on the health economist the feeling of having performed with precision an act of research. Trouble starts when trying to describe the other side of the coin, the benefits achieved; for financial cost makes sense only when compared with non-financial categories of society's value system, and these are notoriously subjective, often elusive, and excruciatingly difficult to translate into pecuniary terms. Drug treatment of "mild hypertension" is a typical example. Lifelong administration of anti-hypertensive drugs is expensive, regardless whether paid by the patient or by society; it is easy to calculate its price. Also, the risk of non-treatment, in patients with slight blood pressure elevations, is rather well defined, amounting to 1 stroke or myocardial infarction in 200-500 patient-years(1). The problem arises when asking the question: is the price to be paid for preventing such an event adequate? After some reflection it must be admitted that measuring costs, assessing benefits, comparing them, and insisting on cost-efficiency is an imperative of contemporary medicine. It is peremptory not only to achieve better, more efficient, more functional health care; cost-benefit considerations are profoundly moral issues as well. In the closed system of resources/care -and we know, it is closed -the boundaries of societal readiness to pay fQr health having been reached, giving cost-ineffective care to one individual means, at best, not giving cost effective care to another individual or, at worst, taking it away from someone. In the last instance, costlbenefit considerations take us back inevitably to the bases of ethics in medicine, or plainly, to the bases of ethics: equity among human beings, solidarity with the sufferers, and the averting of evil (i.e. of disease). These issues cannot and should not be dealt with in a book of this kind. This book gives a valid and accurate review of the state-of-the-art and the problems of costs/benefit IX considerations in selected chronic diseases and it does so with much competence. However, the more we try to apply its teachings to the practice of health care, the closer we get to the basic deontological aspects of medicine. The importance of considering costs and benefits in health care and prevention appears in its real dimensions with the implementation of the findings. Geneva January 1990 Thomas Strasser References (1) Strasser, T.: Mild hypertension studies: A synthetic view. In: H. Hofmann and A. Schrey (editors): Control of Arterial Hypertension in the Prevention of Cardiovascular Disease. Schattauer, Stuttgart New York, 1986 x Commentary It is a fact that even today's financially strongest social systems are no longer able or willing to underwrite all medical achievements, which are appearing at increasingly frequent intervals, with the resources of their health security systems. Working under the slogan "optimum instead of maximum medicine", innovators increasingly see themsel ves under pressure to legitimize their activities by demonstrating not only the medical, but also the economical benefits of their new products, techniques and processes. The articles in this booklet provide an impressive insight into the methodological sophisti cation of the instruments developed for this purpose and into some of the studies in this field. Experience unfortunately teaches that innovations do not succeed on their own merits, even when individual and collective benefits can be convincingly demonstrated. The high level of expertise now evidenced by cost-benefit, cost-effectiveness and quality of life studies contrasts strangely with the degree of acceptance accorded their results by the decision-makers in the health service. In the Federal Republic of Germany at least, there is now a great deal of evidence to suggest that although such studies are the subject of intensive discussion, new products or processes have only expectionally been given precedence in the competition for limited health insurance resources. This scenario invites the conclusion that in order to achieve affluence through innova tions it is not sufficient only to measure their beneficial effects. Since it is not the individuals involved but major collective institutions which decide whether they come into effect in social systems, there will in future also be a need for analyses to determine which of their systems structures promote or impede innovations which offer demonstra ble benefits. Putting health insurance systems on the test bench of efficiency analyses not only contributes greatly to achieving the economic use of scarce resources, it is also an important move towards ensuring that outstanding performance in the field of efficiency measurement in the health service, of the kind presented in this booklet, will abandon the ivory tower of science for good and be able to exert real influence in shaping reality and improving the efficiency of health security systems. Boehringer Mannheim GmbH Dietrich Nord XI
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