Helmholtz Zentrum München, German Research Center for Environmental Health, Institute of Health Economics and Health Care Management, Munich/Neuherberg, Germany.
Eur J Health Econ. 2012 Apr;13(2):127-44. doi: 10.1007/s10198-010-0292-9. Epub 2010 Dec 19.
Over the last decades, methods for the economic evaluation of health care technologies were increasingly used to inform reimbursement decisions. For a short time, the German Statutory Health Insurance makes use of these methods to support reimbursement decisions on patented drugs. In this context, the discounting procedure emerges as a critical component of these methods, as discount rates can strongly affect the resulting incremental cost-effectiveness ratios. The aim of this paper is to identify the appropriate value of a social discount rate to be used by the German Statutory Health Insurance for the economic evaluation of health technologies. On theoretical grounds, we build on the widespread view of contemporary economists that the social rate of time preference (SRTP) is the adequate social discount rate. For quantifying the SRTP, we first apply the market behaviour approach, which assumes that the SRTP is reflected in observable market interest rates. As a second approach, we derive the SRTP from optimal growth theory by using the Ramsey equation. A major part of the paper is devoted to specify the parameters of this equation. Depending on various assumptions, our empirical findings result in the range of 1.75-4.2% for the SRTP. A reasonable base case discount rate for Germany, thus, would be about 3%. Furthermore, we deal with the much debated question whether a common discount rate for costs and health benefits or a lower rate for health should be applied in health economic evaluations. In the German social health insurance system, no exogenously fixed budget constraint does exist. When evaluating a new health technology, the health care decision maker is obliged to conduct an economic evaluation in order to examine whether there is an economically appropriate relation between the value of the health gains and the additional costs which are given by the value of the consumption losses due to the additional health care expenditures. Therefore, a discount rate lower than the SRTP for consumption should be applied if an increase in the consumption value of health is expected. However, given the limited empirical evidence on the relationship between consumption and the value of health, it is hardly possible to make reliable forecasts of this value. Regarding the practice of the German evaluation authority, it is not recommended to use differential discounting in the base case. Instead, the issue of differential discounting should be addressed in sensitivity analyses. Reducing the discount rate for health compared to the rate for costs by a figure in the range between near 0% and 3% may be considered to be appropriate for Germany.
在过去的几十年中，越来越多的医疗保健技术经济评估方法被用于为报销决策提供信息。有一段时间，德国法定健康保险利用这些方法来支持专利药物的报销决策。在这种情况下，折扣程序成为这些方法的一个关键组成部分，因为折扣率会强烈影响最终的增量成本效益比。本文的目的是确定德国法定健康保险在健康技术经济评估中使用的适当社会折现率。从理论上讲，我们基于当代经济学家的普遍观点，即社会时间偏好率（SRTP）是适当的社会折现率。为了量化 SRTP，我们首先应用市场行为方法，该方法假设 SRTP 反映在可观察的市场利率中。作为第二种方法，我们从最优增长理论中推导出 SRTP，使用拉姆齐方程。本文的很大一部分用于指定该方程的参数。根据各种假设，我们的实证结果得出的 SRTP 范围在 1.75%至 4.2%之间。因此，德国一个合理的基准折现率约为 3%。此外，我们还处理了一个备受争议的问题，即是否应该在健康经济评估中应用成本和健康效益的共同折现率或健康的较低折现率。在德国社会健康保险制度中，不存在外生固定的预算约束。在评估一种新的健康技术时，医疗保健决策者有义务进行经济评估，以检查健康收益的价值与因额外医疗支出而导致的消费损失的额外成本之间是否存在经济上适当的关系。因此，如果预期健康的消费价值增加，则应使用低于 SRTP 的消费折现率。然而，鉴于消费与健康价值之间关系的有限经验证据，几乎不可能对该价值做出可靠的预测。关于德国评估机构的实践，不建议在基准情况下使用差异折现。相反，应该在敏感性分析中解决差异折现问题。与成本相比，将健康的折现率降低到接近 0%至 3%之间的数字可能被认为是适合德国的。
