Back to blogging

Now that it is the time of year in which I teach, I will be blogging a lot more.

Yesterday, I picked up the issue of American Journal of Public Health I had just received. I read through it and found an interesting editorial--"A Plea for Cost-Effectiveness". This seemed like an interesting editorial in a journal where I have always (perhaps unfairly) perceived the goal of most authors be to help as many people as much as possible--at any cost!

So, I read the editorial with interest. The author made a point about a young medical care provider who had raised a lot of money for cancer treatment for a child in a developing country. The reason to raise cost-effectiveness was that the author realized the difficulty of the contrast between "wanting to do the best for every patient and wanting to maximize health in society" when resources are very scarce.

If the author had simply said that the goal was to increase the use of cost-effectiveness in decision making, I'd have no concerns. However, there are a few things the author suggested that are part of what gives cost-effectiveness a bad name.

First, the author suggested that we should use cost-effectiveness exclusively as the decision criterion for health resource allocation. I can understand the desire to do that. It would make decision making "easier" in some ways--if everyone agreed that the outcome being valued was the right outcome. However, even if you can avoid death from one disease for $300 for each death avoided while it takes $500 to avoid death from another disease, that does not mean that we should ALWAYS take the option that costs less per death avoided. There are a lot of things that cost-effectiveness cannot consider--like the distribution of outcomes among the population.

Second, the author suggested (without any reflection) that disability adjusted life years are a more humane measure than deaths averted. Disability adjusted life years are a concept that focuses on a person's disability and age when assigning a value to avoiding disease. While some people might find this more humane, others may find the notion that a person's disability determines their "worth" repugnant. Others might question the decision to differentiate the value of life and disability based on a person’s age. Finally, the notion that health now is worth more than health in 10 years for the same person also is something that not everyone agrees is humane. While disability adjusted life years may be considered by some to be a reasonable way to represent outcomes, that feeling is not shared universally. That lack of universal agreement on the best outcome feeds back into my first point--if not everyone agrees on the value of the outcome being studied, that makes it very difficult to use cost-effectiveness as the only criterion for making decisions.

Finally, the statement that prevention is more economically efficient than cure is a nice thought. Historically it may have been correct. However, there is no guarantee at this point that every type of prevention is more efficient than every type of cure. While my compassionate side may want to always prevent disease in as many people as possible rather than waiting to see who gets a disease without intervention and treating, there are plenty of times when waiting to see who gets a condition and then treating is the more economically efficient approach.

So, thinking more about the economics of a decision is probably a good idea. Using economics as the only rule without questioning assumptions that are being made will not help economists convince others of the usefulness of their tools or really help society in the end.