Departments of Economics and Public Health Sciences, University of Rochester, Rochester, NY, USA.
Leonard D. Schaeffer for Health Policy and Economics at the University of Southern California, Los Angeles, CA, USA.
Value Health. 2023 Jul;26(7):1003-1010. doi: 10.1016/j.jval.2023.02.001. Epub 2023 Feb 14.
Both private sector organizations and governmental health agencies increasingly use illness severity measures to adjust willingness-to-pay thresholds. Three widely discussed methods-absolute shortfall (AS), proportional shortfall (PS), and fair innings (FI)-all use ad hoc adjustments to cost-effectiveness analysis methods and "stair-step" brackets to link illness severity with willingness-to-pay adjustments. We assess how these methods compare with microeconomic expected utility theory-based methods to value health gains.
We describe standard cost-effectiveness analysis methods, the basis from which AS, PS, and FI make severity adjustments. We then develop how the Generalized Risk Adjusted Cost Effectiveness (GRACE) model assesses value for differing illness and disability severity. We compare AS, PS, and FI against value as defined by GRACE.
AS, PS, and FI have major and unresolved differences between them in how they value various medical interventions. Compared with GRACE, they fail to properly incorporate illness severity or disability. They conflate gains in health-related quality of life and life expectancy incorrectly and confuse the magnitude of treatment gains with value per quality-adjusted life-year. Stair-step methods also introduce important ethical concerns.
AS, PS, and FI disagree with each other in major ways, demonstrating that at most, one correctly describes patients' preferences. GRACE offers a coherent alternative, based on neoclassical expected utility microeconomic theory, and can be readily implemented in future analyses. Other approaches that depend on ad hoc ethical statements have yet to be justified using sound axiomatic approaches.
私营部门组织和政府卫生机构越来越多地使用疾病严重程度衡量标准来调整支付意愿的门槛。三种广泛讨论的方法——绝对短缺（AS）、比例短缺（PS）和公平回合（FI）——都使用了对成本效益分析方法的特别调整和“阶梯”范围，将疾病严重程度与支付意愿调整联系起来。我们评估这些方法与基于微观经济期望效用理论的方法相比，在衡量健康收益方面的表现。
我们描述了标准的成本效益分析方法，AS、PS 和 FI 都是在此基础上进行严重程度调整的。然后，我们介绍了广义风险调整成本效益（GRACE）模型如何评估不同疾病和残疾严重程度的价值。我们将 AS、PS 和 FI 与 GRACE 定义的价值进行了比较。
AS、PS 和 FI 在如何衡量各种医疗干预措施的价值方面存在重大且未解决的分歧。与 GRACE 相比，它们没有正确地纳入疾病严重程度或残疾程度。它们错误地将健康相关生活质量和预期寿命的提高混为一谈，并将治疗效果的大小与每质量调整生命年的价值混淆。阶梯式方法也引入了重要的伦理问题。
AS、PS 和 FI 在很大程度上存在分歧，这表明最多只有一种方法正确地描述了患者的偏好。GRACE 提供了一种基于新古典期望效用微观经济学理论的连贯替代方案，并且可以在未来的分析中轻松实施。其他依赖于特别伦理声明的方法尚未使用合理的公理方法进行证明。
