TOWARD A BROADER VALUE FRAMEWORK FOR HEALTH TECHNOLOGY ASSESSMENT: EXPANDED COST-EFFECTIVENESS ANALYSIS

Purpose: The purpose of this policy analysis is to identify and define potentially useful expansions to traditional cost-effectiveness analysis (CEA) used as a part of health technology assessment (HTA).  Since the seminal paper by Weinstein and Stason (1977), the recommended approach has been the use of the incremental cost-effectiveness ratio (ICER) using the metric of the cost per quality-adjusted life year (QALY) gained, thus allowing comparisons across different technologies. The U.S. Public Health Service Panel on Cost-Effectiveness (1996) and the UK National Institutes of Health and Care Excellence (NICE; 1999) embraced this measure.  In the past two years, a number of professional societies (e.g., ASCO and ACC/AHA) and organizations (e.g., ICER, NCCN, and Sloan-Kettering) have defined “value frameworks” for application in various contexts—shared decision-making, clinical guidelines development, and HTA.  And industry-related organizations (such as NPC and PhRMA) developed and promulgated some general principles for value frameworks.

Method: Our policy analysis posits that value frameworks should address three key questions:  1) what are the elements of value?; 2) how are they measured, evidenced, and valued?; and 3) how are they aggregated and judged to reach a decision on value?  Current proposed approaches to value frameworks are critiqued in relation to (a) these questions, (b) historically recommended best practices, and (c) proposed principles. 

Result: Recently proposed value frameworks each have serious shortcomings as measures of value.  An expanded framework, incorporating a wider range of the elements of value, is proposed.  In addition to the core value drivers of health gain and cost-offsets, we propose that seven other elements deserve consideration:  some more common ones (e.g., productivity and impacts on other sectors), and some less recognized ones related to information and the value of knowing (i.e., uncertainty reduction, value of hope, real option value, insurance value, and scientific spillovers).  We explore alterative ways to measure and aggregate these---from monetizing them to inclusion in multi-criteria decision analysis or in a deliberative process.

Conclusion: The elements of value for HTA need to be expanded beyond health gain and medical cost-offsets, and there is no one best way to scale, score, and weight these elements.  Decision context is important, and decision support tools are essential. Alternative approaches to reaching decisions are possible, and are likely to be complementary.