Health-Related Productivity Loss: NICE to Recognize Soon, Good to Discuss Now

Abstract

The National Institute for Health and Care Excellence (NICE) will soon consider the societal benefit of drugs, including their impact on productivity. Chief Executive Sir Andrew Dillon says NICE was asked by the Department of Health ‘‘to take account of wider societal benefit. For example, if we have a condition that significantly reduces our ability to undertake the daily activities that most of us would regard as normal, such as paid employment or caring for children or relatives’’ [1]. Until now, NICE has upheld that only health sector costs may be incorporated in cost-effectiveness analyses, not the ‘indirect’ costs such as productivity loss [2, 3]. Numerous reasons were given for this position, e.g., productivity costs were outside the budget purview or incorporating them would discriminate against non-working populations, including the elderly [4]. Critics of NICE retorted that ignoring productivity was tantamount to discrimination against the young, to valuing marginal gains in labor output at zero [4]. Time and again, NICE put these arguments aside. Why the sudden change of heart? It calls to mind the UK’s recent attempt to replace its Pharmaceutical Price Regulation Scheme (PPRS), a voluntary agreement between the Association of the British Pharmaceutical Industry and the government and set to expire in December 2013, by a system of ‘value-based pricing’ (VBP). In light of criticism that the costeffectiveness-based threshold set by NICE was too high, VBP was promoted as a new way to link the price of medications to their value to patients and society. Talks around VBP brought together various lobbies, who agreed that VBP should take the ‘societal perspective’ and account for productivity loss. Although the VBP policy initiative died on the table (the PPRS of old is still in effect [5], albeit with caps on overall pharmaceutical spending growth over the next few years), the beneficiary of this round of politicking is the societal perspective. This is indeed good news for the welfarists. There are, however, issues around the measurement and valuation of productivity loss that have been given short shrift. Our aim is to highlight some of these issues, as cost-effectiveness studies incorporating productivity are likely to advance quickly in the wake of NICE’s decision. The inclusion of productivity losses in cost-effectiveness analyses has always provoked concerns over measurement and valuation, including problems around double-counting, equity, and perspective [6, 7]. Despite these concerns, decision making will be best informed if studies of new drugs explicitly include all societal costs related to the disease being treated. By clearly presenting all cost components separately alongside methodological assumptions, decision makers will be permitted to assess the impact of different assumptions on the final study results. This has been supported by the recent reporting guideline, Consolidated Health Economic Evaluation Reporting Standards [8, 9]. So what components of productivity loss should be considered? People may lose their paid employment because of their health problems (job loss or early retirement). For people maintaining paid employment, some will reduce their routine work time, or experience periodic absences because of their poor health. While people are W. Zhang A. H. Anis (&) Centre for Health Evaluation and Outcome Sciences, St Paul’s Hospital, 588-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada e-mail: aslam.anis@ubc.ca