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Prof. dr. Lieven Annemans
16/05/2014
(Geestelijke)
gezondheidszorg door een
gezondheidseconomische bril
Lieven Annemans
Universiteit Gent, VUB
Mei 2013
Outline
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•
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The problems and goals of health care systems
The solution: cost-effectiveness
What about interventions in psychiatry?
Problems (again)
Discussion
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Prof. dr. Lieven Annemans
16/05/2014
What’s the problem for our health
systems?
1. Health expenditure has been
growing faster than the economy
2. Too much unnecessary and
inadequate care
3. Undertreatment and waiting lists
4. Lack of coordination between
health professionals
5. Inequities in access to care
source: OECD 2009
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De gevolgen van de crisis
Average OECD public health expenditure growth rates in real
terms, 2000 to 2011
7,0%
6,0%
5,0%
4,0%
3,0%
2,0%
1,0%
0,0%
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
Source: OECD Health Data 2013.
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Prof. dr. Lieven Annemans
16/05/2014
BUT let’s not forget the goal of
health care systems
• Primary goal of health care policy =
to maximize the health of the population within the
limits of the available resources, and within an ethical
framework built on equity and solidarity principles.
Report of the Belgian EU Presidency, adopted by the EU
Council of Ministers of Health in Dec 2010
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“Health is a value in itself.
It is also a precondition for
economic prosperity.
People’s health influences
economic outcomes in terms
of productivity, labour supply,
human capital and public
spending.”
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Prof. dr. Lieven Annemans
16/05/2014
The three key ‘values’ of health
policy
QUALITY
SUSTAINABILITY
SOLIDARITY
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What does it mean for (new)
treatments?
“We need to stimulate and make available those
treatments that offer an added therapeutic benefit at
an acceptable cost ( are cost-effective), and fill unmet
medical needs”
- OECD 2003
- Report of the Belgian EU Presidency, adopted by the EU Council of Ministers of Health
in Dec 2010
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Prof. dr. Lieven Annemans
16/05/2014
Cost
Cost-effectiveness
Bad
“intervention”
Good
Current
care
Very Good
(dominant)
Health effect
(QALY)
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QALY: quality adjusted life years
INDEX (“utility level”)
Perfect
health
1
0.6
0.5
+10
+4
20
Death
+5
0
40
50
TIME
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Prof. dr. Lieven Annemans
16/05/2014
Voorbeeld in depressie
Health utility
Utility scores by disease severity over time
0.9
Disease severity
0.8
Mild
0.7
Moderate
0.6
0.5
Severe
0.4
0.3
1
2
3
4
5
6
Visits
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Sobocki P, et al. Value Health. 2007 Mar-Apr;10(2):153-60.
PROBLEEM: waar ligt de grens?
• HISTORICAL BENCHMARK 50,000€ per QALY:
= cost effectiveness of caring for a dialysis patient
(+/- 4 QALYs gained for an investment of +/- 200,000€)
• Desaigues et al (2007): willingness to pay method
€40,000 for a Healthy Life Year (for EU25)
• WHO (2003): 1 x GDP per capita (e.g. Belgium = +/€34000)
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Prof. dr. Lieven Annemans
16/05/2014
Examples
Behandeling of andere interventie
Vaccinatie van ouderen tegen griep
Cost per QALY
gained (+/-) (€)
dominant
Rookstopprogramma’s
3000
Cholesterolverlagers in secundaire preventie
6000
Screenen voor dikkedarm kanker met iFOBt (+/- 50-+/- 70j)
7000
Prezista in HIV/AIDS
13000
Totale Heupprothese
15000
Velcade in multiple myeloma
31000
Tysabri in multiple sclerose
Nierdialyse
47000
50000
Jaarlijkse mammografie bij vrouwen 60-69 jaar
110000
EKG voor alle mannen van 40 jaar oud
124000
Jaarlijkse CT scan bij ex rokers
1300000
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Outline
•
•
•
•
•
The problems and goals of health care systems
The solution: cost-effectiveness
What about interventions in psychiatry?
Problems (again)
Discussion
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Prof. dr. Lieven Annemans
16/05/2014
Example: assertive community treatment in
patients with schizophrenia dominant
QALY: 0.1 gain
(p = 0.001)
Karow et al, J Clin Psychiatry 2012
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Example 2: Depression: combination
(psycho + pharma) vs pharma alone
Simon et al, Br J Psych, 2006
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Prof. dr. Lieven Annemans
16/05/2014
Results (15 months)
Simon et al, Br J Psych, 2006
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Outline
•
•
•
•
•
The problems and goals of health care systems
The solution: cost-effectiveness
What about interventions in psychiatry?
Problems (again)
Discussion
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PC Sint-Jan-Baptist - Academische zitting
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Prof. dr. Lieven Annemans
16/05/2014
Problem 1: Typical characteristics of the health care
system
• Uncertainty
Health insurance
• Moral hazard,
• “adverse selection”
• Asymmetric information
Possibility of supplier-induced demand!
• Externalities
– Societal values > individual values
Need for a strong, performant and flexible
government
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Is mental health care
different from other
care?
“Schizophrenia is just like cancer”
Rubenstein
Wat bedoelde hij?
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Prof. dr. Lieven Annemans
16/05/2014
The market for mental health care
IS different
• Moral Hazard and Adverse selection apply
with particular force
• Asymmetry of information: applies with
particular force (in some mental illnesses)
• More externalities: e.g. crime, violence, …
Larger role for government
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Problem 2: the financing system
Increasing focus on saving own money
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Prof. dr. Lieven Annemans
16/05/2014
2 questions: who gains more
money?
• Admission for schizophrenia
– Setting A: no re-admission within 1 month
– Setting B: re-admission within 1 month
• Admission of alzheimer’s patient
– Setting A: no nosocomial infection
– Setting B: nosocomial infection
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More Pay for Quality
• ‘the systematic and deliberate use of payment
incentives that recognize and reward high levels
of quality and quality improvement’. (The Institute
of Medicine, 2007)
Explicit link between quality achievement and payment
BUT: What is quality? Do we have the data? What
types of incentives to provide? What about the
confounders?…..
(Annemans et al. KCE report 2010)
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Prof. dr. Lieven Annemans
16/05/2014
Sometimes fantastic results!
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Sometimes less…
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Prof. dr. Lieven Annemans
16/05/2014
Problem 3: A QALY is not a QALY
INDEX (“utility level”)
1
0.9
?
0.7
0.4
0.2
0
Product X
Disease 1
Product Y
Disease 2
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The importance of medical need.
Cfr. Social reference point (Scitovsky)
maximal
Health status
Striving above SRP
Pleasure seeking
Not necessary
No funding
Striving towards SRP
Necessity depends on
severity
Accept higher
cost/QALY in worst
conditions
Societal
reference
point
-Age
- Socio-economic
- QALY history
minimal
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Prof. dr. Lieven Annemans
16/05/2014
Problem 4: Uncertainty: potential value
PAYER
The typical
Dilemma
“Give us more
evidence that your
approach is value
for money”
YOU
“But we will only be
able to provide
evidence in the real-life
Give us first
reimbursement”
Example: healthy nutrition and physical activity
in inhabitants of sheltered houses
DSM-IV diagnose (in %)
45
40
35
30
25
20
15
10
5
0
Dr. Nick Verhaeghe UGent
41,2
30,1
28,9
22,7
15,5 16,9 14,9 13,3
5,7
10,8
I-groep
C-groep
I-groep: interventiegroep; C-groep: controlegroep
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Prof. dr. Lieven Annemans
16/05/2014
Karakteristieken
Variabele
Interventiegroep (n=201)
Controlegroep (n=83)
Gewicht (kg), gemiddeld
87.95
85.19
BMI (kg/m²), gemiddeld
30.22
29.52
106.16
76 (63.9)
70 (85.4)
105.21
29 (52.7)
25 (89.3)
34.17
33.37
3 (1.5)
36 (17.9)
66 (32.8)
96 (47.8)
0 (0)
16 (19.3)
29 (34.9)
38 (45.8)
Buikomtrek (cm), gemiddeld
man ≥102 cm, n (%)
vrouw ≥88 cm, n (%)
Vetpercentage, gemiddeld
BMI categorie, n (%)
ondergewicht
normaal gewicht
overgewicht
obesitas
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Relative risk of having CHD, stroke, diabetes and colon cancer in
individuals with mental disorders
Disease
coronary heart disease
stroke
Age (years)
Relative risk
18-49
1.42
50-75
1.01
18-49
1.77
50-75
1.77
diabetes
1.77
colon cancer
2.90
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Prof. dr. Lieven Annemans
16/05/2014
Resultaten: effect op BMI (kg/m²)
-0,2
-0,1
0
0,1
0,2
0,3
0,4
-0,12
T1-T0
0,08
interventiegroep (n=201)
controlegroep (n=83)
(p = 0.04)
0,11
T2-T0
0,35
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Effect of BMI decrease (if maintained)
Health state
Relative risk reduction if 1
kg/m² BMI decrease (%) Risk reductions in study (%)
men
women
men
women
CHD
4.7
5.7
Stroke
6.0
8.5
0.94
1.20
1.14
1.70
Diabetes
13.0
11.0
2.60
2.20
Colon cancer
5.2
2.0
1.04
0.40
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Prof. dr. Lieven Annemans
16/05/2014
Resultaten kosteneffectiviteit
(projectie over 20 jaar)
Mannen
ICER (€/QALY)
Base case
44.693
Scenario 1
22.810
Scenario 2
91.236
Scenario 3
4.127
Scenario 1: full compliance
Scenario 2: programma 2x/jaar
Scenario 3: toename kwaliteit van leven t.g.v. daling BMI
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More Performance based
agreements?
Performance Based agreements =
formal agreements where the
reimbursement of a treatment is related
to the future performance of the
treatment in in a real life situation.
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Prof. dr. Lieven Annemans
16/05/2014
Discussion
• Health economics is always about 2 dimensions:
costs and health effects
• To achieve our health care goals we need to
embrace health economic principles
• Avoid waste or less cost-effective care to reinvest
in more quality, innovation and prevention
• Only when financial incentives encourage costeffective care they are acceptable
• BUT: issues of uncertainty, ethical aspects, ….
• Mental health workers need to get engaged!
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De toekomst ziet er zeer goed uit…
Voor gezondheidseconomen
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Prof. dr. Lieven Annemans
16/05/2014
Derde druk
Verkrijgbaar
in elke
boekhandel
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