Chris Sampson’s journal round-up for 5th September 2016

Every Monday our authors provide a round-up of some of the most recently published peer reviewed articles from the field. We don’t cover everything, or even what’s most important – just a few papers that have interested the author. Visit our Resources page for links to more journals or follow the HealthEconBot. If you’d like to write one of our weekly journal round-ups, get in touch.

The effect of complementary private health insurance on the use of health care services. International Journal of Health Economics and Management Published 31st August 2016

Moral hazard is one of the key ideas taught to fledgling health economists, but having taken flight you don’t hear all that much about it. That’s because most of us live in Europe, enjoying our universal publicly funded health care systems. But I quite like papers that remind me that moral hazard is still a going concern and that my MSc was relevant. This paper looks at the impact of complementary private health insurance – that is, alongside a national health service. There aren’t so many studies of moral hazard in this setting. Private health insurance (let’s call it PHI) might decrease use of public health care (let’s call it NHS), but it might also increase pressure on the NHS by creating additional demand. For example, people might need a referral from an NHS GP in order to qualify for PHI coverage. This study uses cross-sectional questionnaire data from Denmark, collected from 5447 individuals for the purpose of this study. The questionnaire collected all sorts of data relating to health care use and sociodemographics. People who gave ‘Don’t know’ or ‘Other’ responses were dropped, meaning that only 4362 were analysed. 49% of the sample had PHI – the ‘treatment’ of interest. The authors use a bivariate probit model with propensity score matching to predict health care use. Furthermore, an instrumental variable is used to improve identification. Having PHI seems to increase use of services, with strong effects for prescription medicine, dentist visits and chiropractors. This suggests that PHI coverage may contribute to increasing national health care costs. There are some major limitations to this study, which the authors acknowledge. The response rate was 41%, and the sample wasn’t particularly representative. The one thing I can’t get my head around is the authors’ identification strategy. The instrumental variable chosen was whether or not an individual wears glasses, as in this case PHI is particularly favourable. Even controlling for the covariates used in this analysis, I cannot see (no pun intended) how this could be unrelated to health care use.

The value of disease prevention vs treatment. Journal of Health Economics Published 29th August 2016

The public’s view of pharma just keeps getting worse“, apparently. One probably-entirely-made-up-but-sort-of-reasonable-sounding thing I’ve heard Joe Public say in the past is that Pharma would like us all to remain sickly cash cows. New treatments = milk. Prevention is just… soya. That analogy made no sense, but there are also more reasoned arguments that we spend too much on treatment and too little on prevention. There are also numerous studies characterising people’s preferences regarding prevention and treatment under different conditions. This study builds on this background by developing a utility model of disease valuation in order to derive willingness-to-pay values for reductions in incidence (prevention), mortality (treatment) or deterioration in quality of life (palliative care). The basis for the model is 3 possible states – healthy, ill and dead – through which people can progress in only one direction (i.e. there is no cure). The ‘ill’ state relates to a specific disease and has a value somewhere between 1 (healthy) and 0 (dead). The authors use the model to determine – for example – how willingness to pay for improvement in the ‘ill’ state might be affected by the mortality rate. Two key implications of the model are that i) when the risk of dying from a disease is greater than the incidence rate, prevention is more valuable than treatment and ii) when the incidence rate is greater than the decline in quality of life, prevention is more valuable than palliative care. The model is also used to incorporate probability weighting to give a more realistic characterisation of people’s risk preferences. In most cases, the two previous findings will hold. An interesting finding of this part of the analysis is that it seems to partly explain people’s disproportionately strong preferences for treating more severe diseases. The model suggests that prevention is more valuable than treatment for most real-world situations, and so we’ve probably got the balance all wrong.

Does one size fit all? Assessing the preferences of older and younger people for attributes of quality of life. Quality of Life Research [PubMed] Published 23rd August 2016

There’s plenty of talk nowadays about the idea that QALYs don’t reflect the most important objects of value for particular groups of people, especially older people. Non-health improvements in quality of life might be more important. Whether we’re using EQ-5D, SF-6D, HUI3 or your personally preferred multi-attribute utility measure, the idea is that they’re measuring the same thing. But they’re not. They consistently give systematically different results. This study sought to find out if older people value quality of life attributes used in these measures differently to younger people. The authors elicit preferences for different domains using a web-based survey of two groups of 500 people: over 65s and 18-64 year olds. Individuals were presented with 12 descriptors from the EQ-5D, AQoL and ASCOT and asked to complete both a ranking and a best worst exercise. Socioeconomic data were also collected. The two cohorts ranked the domains differently, but perhaps not as differently as we might expect. ‘Independence’ was important to both groups, with 36% of over 65s and 20% of 18-64 year olds ranking it first. Physical mobility, mental health and pain also ranked highly for both groups. Older people ranked control, self-care and vision more highly than younger people, who in turn ranked safety, social relationships, dignity, sleep and hearing more highly. The results from the ranking exercise and the best worst exercise were similar. So, non-health attributes matter to everyone and older people’s preferences differ to younger people’s. But so what? We could probably find differences between a sample of men and a sample of women, or between an urban and a rural population. The question is: which differences matter? Studies like this are useful, but they can’t tell us how we ought to handle heterogeneous preferences.

From representing views to representativeness of views: Illustrating a new (Q2S) approach in the context of health care priority setting in nine European countries. Social Science & Medicine [PubMedPublished 22nd August 2016

Asking the public what they think; it’s a dangerous game (nb Brexit, Boaty McBoatface, Mrs Brown’s Boys). But there are good grounds for doing so when it comes to health care resource allocation. This paper comes from an ongoing research project that I’ve written about on a couple of occasions. A previous paper used Q methodology and identified 5 viewpoints regarding the fundamental basis for the allocation of resources in health care, titled: 1) ‘egalitarianism, entitlement and equality of access’, 2) ‘severity and the magnitude of health gains’, 3) ‘fair innings, young people and maximising health benefits’, 4) ‘the intrinsic value of life and healthy living’ and 5) ‘quality life is more important than simply staying alive’. This study developed a new methodology called Q2S, designed to extract features from the viewpoints elicited through the original Q study and create a survey to find out how these different viewpoints are represented in society. Data were collected from 39,560 respondents from 9 European countries. Participants were presented with a series of descriptions with which to identify agreement on a 7-point Likert scale from “very unlike my point of view” to “very much like my point of view”. 41% of respondents gave their highest score to a single viewpoint, while the rest tied across two or more viewpoints and were subsequently asked to identify which one would best reflect their view. 43% of respondents were allocated to Viewpoint 1. This viewpoint asserts that health care is a basic right, that treatment effectiveness is essentially irrelevant because all life has the same value, and that scarcity is not a concern. It was predominant in all 9 countries. Gulp! Next up with 17% was Viewpoint 2, which is a bit closer to health maximisation but with a preference for allocation to life-saving treatment and more severe health states. Viewpoint 3 was not popular, with only 4% of people identifying it as most like their point of view. The authors identify various associations between sociodemographic variables and likelihood of particular viewpoints. There’s a lot of food for thought in this paper. Where do you sit? My position changes depending on how revolutionary I’m feeling.

Photo credit: Antony Theobald (CC BY-NC-ND 2.0)

#HEJC for 24/10/2014

The next #HEJC discussion will take place Friday 24th October, at 1pm London time on Twitter. To see what this means for your time zone visit Time.is or join the Facebook event. For more information about the Health Economics Journal Club and how to take part, click here.

The paper for discussion is a working paper published by Glasgow Caledonian University’s Yunus Centre. The authors are Neil McHugh and colleagues. The title of the paper is:

Extending life for people with a terminal illness: a moral right or an expensive death? Exploring societal perspectives

Following the meeting, a transcript of the Twitter discussion can be downloaded here.

Links to the article

Direct: http://www.gcu.ac.uk/media/gcalwebv2/ycsbh/yunuscentre/Extending%20Life%20for%20People%20with%20a%20Terminal%20Illness.pdf

RePEc: https://ideas.repec.org/p/yun/hewpse/201403.html

Summary of the paper

A lot of research effort has been spent on whether health economists’ most ingrained normative assumption should hold; is a QALY of equal value regardless of to whom it accrues. In the UK, the National Institute for Health and Care Excellence has given weighting to ‘special cases’; namely, life-extending drugs for patients near the end of their life (mainly for cancer). However, existing empirical research about whether societal values support such a weighting has given conflicting results.

McHugh et al, in their new working paper, present the first major mixed methods study of societal perspectives for QALY-weighting. The authors use Q methodology – which involves the ranking of opinion statements according to agreement – to elicit societal perspectives on the relative value of life extension for people with terminal illness. Opinion statements were collected from 4 sources:

  • newspaper articles
  • a NICE public consultation
  • 16 interviews with key informants
  • 3 focus groups with the general public

The Q sort was conducted with people from academia, the pharmaceutical industry, charities, patient groups, religious groups, clinicians, people with experience of terminal illness and a sample of the general public. The authors’ final sample included 61 Q sorts and factor analysis identified 3 distinguishable perspectives, which can be summarised as:

  1. A population perspective (value for money, no special cases)
  2. An individual perspective (value of life, not cost)
  3. A mixed perspective

Factor 1 individuals are unlikely to support any QALY-weighting, maintaining a utilitarian-type health-maximising perspective. Factor 2 respondents reject the denial of life extending treatments and assert that patients and their families should decided whether or not they wish to receive the treatment; regardless of cost. This group appear to disagree with cost-effectiveness analysis altogether. Factor 3 represents a more nuanced view, asserting that value is broader than health gain alone. However, factor 3 was associated with a focus on quality of life, and so support for expensive life-extending treatment would depend on this. It is unclear whether QALY-weighting would adequately achieve this.

Discussion points

  • Is the question of QALY-weighting a normative one or a positive one?
  • Are the three factors likely to be robust across ethical dilemmas other than terminal illness?
  • To what extent are the opinions associated with the 3 factors likely to be robust to further deliberation?
  • Are factor 2 respondents simply wrong?
  • Should QALY-weighting be based on democratic processes?
  • Is it of concern that current policy appears to reflect the views of health economists better than other groups?
  • Where do you stand?

Can’t join in with the Twitter discussion? Add your thoughts on the paper in the comments below.