School of Health and Society, University of Wollongong, Wollongong, NSW, Australia.
Front Public Health. 2024 Mar 6;12:1212439. doi: 10.3389/fpubh.2024.1212439. eCollection 2024.
Given constrained healthcare budgets and many competing demands, public health decision-making requires comparing the expected cost and health outcomes of alternative strategies and associated adoption and financing actions. Opportunity cost (comparing outcomes from the best alternative use of budgets or actions in decision making) and more recently net benefit criteria (relative valuing of effects at a threshold value less costs) have been key concepts and metrics applied toward making such decisions. In an ideal world, opportunity cost and net benefit criteria should be mutually supportive and consistent. However, that requires a threshold value to align net benefit with opportunity cost assessment. This perspective piece shows that using the health shadow price as the ICER threshold aligns net benefit and opportunity cost criteria for joint adoption and financing actions that arise when reimbursing any new strategy or technology under a constrained budget. For an investment strategy with ICER at the health shadow price = 1/(1/ + 1/-1/), net benefit of reimbursing (adopting and financing) that strategy given an incremental cost-effectiveness ration (ICER) of actual displacement, , in financing, is shown to be equivalent to that of the best alternative actions, the most cost-effective expansion of existing programs (ICER = ) funded by the contraction of the least cost-effective programs (ICER = ). Net benefit is correspondingly positive or negative if it is below or above this threshold. Implications are discussed for creating pathways to optimal public health decision-making with appropriate incentives for efficient displacement as well as for adoption actions and related research.
鉴于医疗保健预算有限且存在许多竞争需求，公共卫生决策需要比较替代策略以及相关采用和融资措施的预期成本和健康结果。机会成本（在决策中比较预算或行动的最佳替代用途的结果）和最近的净效益标准（在低于成本的阈值处对效果的相对评估）一直是用于做出此类决策的关键概念和指标。在理想情况下，机会成本和净效益标准应该相互支持和一致。然而，这需要一个阈值来使净效益与机会成本评估保持一致。本文认为，在受约束的预算下，为任何新策略或技术进行补偿时，使用健康影子价格作为增量成本效益比（ICER）阈值，可以使联合采用和融资措施的净效益和机会成本标准保持一致。对于 ICER 等于健康影子价格 1/(1/ + 1/-1/)的投资策略，如果实际增量成本效益比（ICER）为实际置换的增量成本效益比（ICER），则补偿（采用和融资）该策略的净效益与最佳替代行动（ICER = ）的净效益相同，即通过收缩成本效益最低的项目（ICER = ）来为现有项目的最有效扩展（ICER = ）提供资金。如果低于或高于此阈值，则净效益相应为正或负。本文还讨论了为实现最佳公共卫生决策创造途径的意义，以及为有效的替代和采用行动及相关研究提供适当的激励措施。
