Lomas James, Claxton Karl, Martin Stephen, Soares Marta
Centre for Health Economics, University of York, UK.
Centre for Health Economics, University of York, UK; Department of Economics and Related Studies, University of York, UK.
Value Health. 2018 Mar;21(3):266-275. doi: 10.1016/j.jval.2017.10.006. Epub 2018 Jan 4.
Considering whether or not a proposed investment (an intervention, technology, or program of care) is affordable is really asking whether the benefits it offers are greater than its opportunity cost. To say that an investment is cost-effective but not affordable must mean that the (implicit or explicit) "threshold" used to judge cost-effectiveness does not reflect the scale and value of the opportunity costs. Existing empirical estimates of health opportunity costs are based on cross-sectional variation in expenditure and mortality outcomes by program budget categories (PBCs) and do not reflect the likely effect of nonmarginal budget impacts on health opportunity costs. The UK Department of Health regularly updates the needs-based target allocation of resources to local areas of the National Health Service (NHS), creating two subgroups of local areas (those under target allocation and those over). These data provide the opportunity to explore how the effects of changes in health care expenditure differ with available resources. We use 2008-2009 data to evaluate two econometric approaches to estimation and explore a range of criteria for accepting subgroup specific effects for differences in expenditure and outcome elasticities across the 23 PBCs. Our results indicate that health opportunity costs arising from an investment imposing net increases in expenditure are underestimated unless account is taken of likely nonmarginal effects. They also indicate the benefits (reduced health opportunity costs or increased value-based price of a technology) of being able to "smooth" these nonmarginal budget impacts by health care systems borrowing against future budgets or from manufacturers offering "mortgage" type arrangements.
考虑一项拟议的投资（一种干预措施、技术或护理方案）是否负担得起，实际上是在问它所带来的收益是否大于其机会成本。说一项投资具有成本效益但却负担不起，必然意味着用于判断成本效益的（隐含或明确的）“阈值”没有反映机会成本的规模和价值。现有的健康机会成本实证估计是基于按项目预算类别（PBC）划分的支出和死亡率结果的横断面变化，并未反映非边际预算影响对健康机会成本的可能影响。英国卫生部定期更新基于需求的国家医疗服务体系（NHS）地方区域资源目标分配，从而形成两个地方区域子组（目标分配以下的区域和目标分配以上的区域）。这些数据提供了一个机会，来探究医疗保健支出变化的影响如何因可用资源而异。我们使用2008 - 2009年的数据来评估两种计量经济学估计方法，并探索一系列标准，以接受23个PBC中支出和结果弹性差异的子组特定效应。我们的结果表明，除非考虑到可能的非边际效应，否则因投资导致支出净增加而产生的健康机会成本会被低估。它们还表明，通过医疗保健系统利用未来预算借款或制造商提供“抵押”式安排来“平滑”这些非边际预算影响所带来的益处（降低健康机会成本或提高技术的基于价值的价格）。
