2006 seminars - Centre for Health Economics, University of York

Past CHE Seminars 2006

7 December 2006

Title: The political economy of patient choice
Speaker: Professor Julian Le Grand. London School of Economics.

Abstract: The seminar will consider the relationship between the arguments for and against extending patient choice, and the interests of those putting forward those arguments. It will draw in part on Julian Le Grand's experience as senior health policy adviser at No 10 Downing St.

2 November 2006

Title: Dangerous omissions: The consequences of ignoring decision uncertainty
Speaker: Susan Griffin, Centre for Health Economics, University of York.

Abstract: Institutions with the responsibility for making adoption (reimbursement) decisions in health care often lack the remit to demand or commission further research: adoption decisions are their only policy instrument. The decision to adopt a technology influences the prospects of acquiring further evidence (incentives to conduct research are reduced and the ethical basis of further clinical trials are undermined). The opportunity loss of adoption includes the value of information generated by research which may be forgone. The opportunity loss of rejecting an apparently cost-effective technology includes expected net benefit forgone. Using decision theory and value of information analysis we establish decision rules based on these expected opportunity losses, incorporating uncertainty around the arrival of new evidence. Technologies should be rejected when the expected opportunity loss of adoption (expected value of information forgone) exceeds the opportunity loss of rejection (expected net benefit forgone). We demonstrate that a sufficient condition for immediate adoption of a technology can provide incentives for sponsors to reduce the price or provide additional supporting evidence. For agencies without control over research, decisions based solely on expected net benefit do not account for the opportunity losses of adoption, provide no such incentives and may undermine the evidence base for future clinical practice.

23 October 2006

Title: Health Care Reform in Germany – Sustainability and Financing Health Care
Speaker: Udo Schneider

Abstract: The German Statutory Health Insurance scheme faces enormous future problems due to demographic change combined with medical-technological progress. Increasing health care expenditures and the weakness of the revenue base will lead to rising contribution rates. The main problem is that younger generations will have to finance the higher expenditure profiles for older individuals. This financial burden on future generations raises the question of how the SHI can be reformed to achieve a more sustainable health care system. Using the concept of implicit tax our projections show how different reform proposals influence sustainability and the extent to which intergenerational redistribution can be reduced.

9 October 2006

Title: Understanding NHS deficits: hypotheses and evidence
Speaker: Barry McCormick, Chief Economic Adviser, Department of Health

5 October 2006

Title: Project and system failure
Speaker: Peter Dick, OR Programme Manager, Standard and Quality Analytical Team, Department of Health

Abstract: This presentation will review some of the literature on project failure and system failure and, with reference to some well-known and not-so-well-known examples, attempt to draw out some lessons from bad decisions and bad decision-making.

The talk will try to map out common 'pathways to failure' (illustrated with examples from the public and private sector), to identify common 'failure traps' often encountered, to discuss alternative mental models of failure and to suggest some general guidelines for avoiding failure in systems and projects.

13 July 2006

Title: Examining the top-side in cost-effectiveness: pharmaceutical pricing in the US and evidence (or not) of competition in the pharmaceutical industry
Speaker: Dan Malone, Ph.D. A Professor of the Colleges of Pharmacy and Public Health, University of Arizona, Tucson, Arizona, USA

Abstract: Considerable effort is made with respect to determining efficacy and effectiveness when conducting cost-effectiveness analyses, but there has been little attention to the top side of the equation for incremental cost-effectiveness ratios. The purpose of this seminar is to examine the various pricing schemes usedin the United States and also to examine pharmaceutical pricing behaviour in the industry in a semi-regulated pricing market.

15 June 2006

Title: Exploring impacts of antiretroviral treatment for HIV/AIDS on labour productivity in high labour intensive production processes - methods and challenges
Speaker: Debbie Muirhead, Health Policy Unit, Department of Public Health and Policy, London School of Hygiene and Tropical Medicine.

Abstract: Of the 42 million people infected with HIV/AIDS across the world, over half of these live in Sub Saharan African. South Africa has one of the largest absolute numbers of individuals living with HIV/AIDS in the world (recently overtaken by India) with over 12% of its 42 million population living with HIV and over 25% of women in reproductive age groups.

Over recent years there has been huge national and international pressure for the rapid scale up of access to antiretroviral treatment (ART). The private sector is playing an increasingly important role of providing access to treatment, including through employer based programmes. Where a large proportion of total societal economic benefit arising from ART accrues to the firm, good economic justification exists for employers to finance treatment for employees, removing some of the burden on the public sector.

Aurum Health is both supporting the provision of ART across a large group of companies and communities as well as undertaking both clinical and economic research alongside the treatment programmes. Currently over 4500 individuals have been placed on ART between Jan 2003 and February 2006 in the employer programme. The programme covers provision at 58 sites across South Africa of which some are hospital, some are occupational health clinic and some are contracted GP sites.

This presentation will try to touch on different areas, particularly of:

A brief introduction of the health policy and health system context and challenges for HIV/AIDS treatment and care in South Africa and the role of the private sector
A description of the economic analysis of costs and productivity benefits of the employer based antiretroviral treatment programme in South Africa
A focus on the econometric methods and challenges for analysis of the productivity benefits arising from ART in two participating companies, both mining companies.

8 June 2006

Title: Establishing the cost effectiveness of pharmaceutical care for the elderly in the UK: results from the RESPECT trial
Speaker: Chris Bojke, Senior Research Consultant, Pharmerit International and Zoe Philips, Visiting Research Fellow, CHE

Abstract: The RESPECT (Randomised Evaluation of Shared Prescribing for Elderly people in the Community over Time) trial aims to investigate the effectiveness and cost effectiveness of 'pharmaceutical care' provided by community pharmacists to elderly patients in the community in the UK.

The trial design is a randomised multiple interrupted time series. 760 patients from 24 general practices, each associated with about three community pharmacies, from each of the five Primary Care Trusts (PCT) in North and East Yorkshire were recruited.

The intervention is the provision of 'pharmaceutical care' in which pharmacists co-operate with doctors, patients and carers in designing, implementing and monitoring a Pharmaceutical Care Plan (PCP). The PCP consists of a detailed record of the patients' history and medications, the establishment of therapeutic goals for each drug-related problem and the identification of potential drug interactions, appropriate doses and feasible alternative treatments. Pharmaceutical Care involves the setup and monitoring of the PCP.

In this seminar we will present the results of the cost-effectiveness analysis, with the focus being on the econometric approach taken in the analysis of the data. To our knowledge, this is the first economic evaluation that has been conducted alongside a trial using a multiple-interrupted time series design and provides a methodological bridge between the rapidly developing fields of cost-effectiveness analysis and applied econometrics.

6 April 2006

Title: Developing new approaches to measuring NHS output and productivity
Speaker: Hugh Gravelle, National Primary Care Research and Development Centre, Centre for Health Economics, University of York.

Abstract: Measurement of NHS productivity growth is controversial and difficult. It requires measures of health sector output which capture the valuable things that the health system produces. This is not straightforward because of difficulties in defining health care outputs and of attaching values to them. I will outline the proposals made by a joint CHE/NIESR research team for improving the measurement of NHS output and productivity by refining the underlying methodology and by collecting new and better data I will also comment on the estimates recently published by ONS which incorporate the suggestions of the research team and some additional ingenious adjustments by the DH.

22 March 2006

Title: The status of pay-for-performance in the United States: evidence from the Community Tracing Study
Speaker: Jon Christianson, Professor of Health Policy and Management, the University of Minnesota.

Abstract: A growing number of individual health plans in the United States are developing and implementing pay-for-performance programs, featuring financial incentives for hospitals and physicians tied to quality and efficiency. The status of their efforts is assessed using information collected as part of the Community Tracking Study, a longitudinal project that follows market-level changes in twelve randomly-selected U. S. communities. In these communities, plans are developing customizedprograms that reflect data availability, concessions to providers, and market idiosyncrasies. As a result, performance measures and program designs vary substantially within and across markets. Within markets, providers are concerned about the administrative burden imposed on them by customized health plan programs, and also by the potential for conflicting financial incentives. The experience with pay-for-performance in local markets to date appears to set the stage for a national effort in the U.S. aimed at addressing provider concerns, while improving program designs.

20 March 2006

Title: Hospital Financing: a bargaining approach.
Speaker: Marisa Miraldo

2 February 2006

Title: Informational spillovers and the sequential launching of pharmaceutical drugs
Speakers: Pau Olivella and Begoña Garcia-Marinoso, Departament d’Economia i d’Història Econòmica, Universitat Autònoma de Barcelona.

Abstract: We analyze informational spillovers in the pricing of drugs, which occur as a result of sequential launching. With sequential launches and asymmetric information about the cost of a drug, the acceptation of a price where the drug is first launched might reveal the firm’s private information to subsequent players. The paper identifies the circumstances where such informational spillovers are possible and explains how the firm will prevent them by crafting the order of launches. The jointly necessary and sufficient conditions for informational spillovers to occur are: (i) the unit subsidy of drugs varies across countries; (ii) the firm enters a country with large aggregate demand first, and (iii) the prior that countries hold about the firm being low cost takes intermediate values. If these conditions hold, a firm will choose to enter first a country with small aggregate demand (in order to prevent the spillover) if and only if the firm is impatient.

12 January 2006

Title: Converting water into wine? Deriving cardinal values for health from ordinal preference data.
Speaker: Paul Kind

Abstract: Economics traditionally treats human behaviour as being rational (albeit sometimes imperfectly so). This powerful assumption conditions the economist to expect that when faced with the task of judging the value of health (states), individuals should make 'rational' choices, for example preferring states with less pain to those with more. Respondents in valuation studies who display logical inconsistency are typically excluded from substantive analysis. Our problem in valuing health is that although we control the mechanism by which preferences are established we have little influence over the internal processing that individuals use in handling the information we present to them. Although think aloud procedures and other qualitative methods have been devised they are not commonly used in valuation studies.

In the analysis of valuations data we tend to rely on external cues to provide evidence of data quality. Illogical, intransitive, irrational choices are removed, leaving behind better residual data on 'true' values. The requirement to do so stems from the underlying assumption that respondents have the capacity to act in a logical manner and illogical choices result solely from faulty information processing. This assessment leads to relatively high attrition rates in valuation data collected using utility assessment methods such as TTO and SG. Data tend to be lost from older, less well educated respondents who are more likely to exhibit currently poor health status. Hence studies designed to elicit social preferences may yield results that are not truly representative of the population they purport to represent.

In practice individuals do not make perfectly consistent choices. The systematic investigation of preferences can be traced back to Thurstone's work in the late 1920s that lead to the formulation of his comparative judgement model based on the experimental procedure known as paired comparisons. This, and other similar models, utilizes the expected inconsistency in individual judgments as a measure of distance between health states (or other entities, from criminal acts to soft drinks). By logging the pairwise comparisons of multiple health states it is possible to synthesise a distribution of values from which a mean value for each state may be computed. Data collected as part of the national MVH study were analysed using Thurstone's model and these result in scale values that display a remarkable degree of similarity when compared to the utilities for the same EQ-5D health states generated using TTO procedures. Paired comparisons and categorical choice models assume lower levels of information than that which underpins TTO or SG. Ordinal (and other nonmetric) models are based on a robust methodology that utilizes information from all respondents. The preference data required by such methods is simpler and less demanding than the intellectual gymnastics of utility elicitation. So, why are such simpler methods that are commonplace in market research not part of the mainstream preference measurement in health? This seminar will present evidence of life after death and describes a way ahead that could lead to simpler, more accessible methods for calibrating values for health.