Page 91 - Effective healthcare cost containment policies Using the Netherlands as a case study - Niek W. Stadhouders

The marginal benefits of healthcare spending in the Netherlands
causality, biasing the threshold upwards. When patient group mortality was estimated using OLS, we obtained a threshold of €49,600 per QALY (€46,000 - €63,000 per QALY). However, estimating the number of deaths based on spending patterns aggravates truncation bias, as negative estimates are not allowed. This may bias the threshold downwards. Although multimorbidity corrections are promising, additional corrections may be required to alleviate bias.
This paper presents a novel method to estimate the opportunity costs of care by combining mortality related outcomes and quality of life of patients into one outcome measure and relating it to changes in spending over time. To this aim, we built upon panel data methodology (Felder, 2006; Hall and Jones, 2004) and QALY estimation methods (Claxton et al., 2015a; Gheorghe et al., 2015), accounting for some of the issues raised in QALY threshold estimation (Barnsley et al., 2013; Raftery, 2014). Results indicate that in the Netherlands, at the margin, a QALY costs between €53.000 and €94.000 to produce, with a point estimate of €73.600. Standard economic theory suggests that under a fixed budget, new technologies would need to have an incremental cost effectiveness ratio (ICER) of below €73.600 per QALY in order to increase population health. Although the analysis is rather inclusive, much uncertainty remains. We discuss how the results relate to earlier findings, the risks of bias of the estimates, the factors that could explain uncertainty and next steps to improve the estimates.
4.4 Discussion
Several studies have estimated thresholds for high-income countries, ranging from €18.000 to €200.000 per QALY (Claxton et al., 2015b; Thokala et al., 2018; Vallejo-Torres et al., 2016; Vallejo‐Torres et al., 2017). Literature suggests that willingness-to-pay (WTP) estimates tend to be higher than supply-side estimates (Vallejo-Torres et al., 2016). Our supply-side estimates are broadly in the same range as Dutch WTP-estimates for hospital care of between €13.000 and €110.000 per QALY (Bobinac et al., 2014; Bobinac et al., 2010; Nimdet et al., 2015).
4.4.1 Relation to the literature
Research from the US find marginal costs to save a life at age 60-64 of around $800,0003 (Hall and Jones, 2004). For Switzerland, a marginal cost to save a life is found between 700.000 Franc to 3,5 million Franc4 (Felder, 2006). These results are consistent with our estimates. Other research finds significantly higher marginal values, i.e. lower
3 At 10.9 healthy life years (table 2), and 2014 dollar exchange rates this would accrue to €69,242 per QALY. 4 This would be between €55,107 and €275,535 per QALY in 2014.
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