Abstract

The Hanover Consensus Group (HCG) has put forward their recommendations for conducting economic evaluations [1]. It is a remarkable achievement to bring together most of the health economics community in Germany. To reach consensus in such a large group, however, much must be left unspecified and the exercise tends to be a search for the lowest common denominator. As strongly suggested by the HCG, the perspective, the selection of instruments, as well as the normative requirements for health economic evaluation depend on the decision-maker. It is surprising therefore that the authors of a report purporting to be “German recommendations” did not consider the German decision-making context based on the New Health Act nor the way the German Federal Joint Committee (G-BA) will give assignments to the Institute for Quality and Efficiency in Health Care (Institut fur Qualitat und Wirtschaftlichkeit im Gesundheitswesen, IQWiG). The legal requirements for assessments of the relation of costs to benefits of health technologies are embedded in the recent German legislation (Social Code Book V § 35b). The specific constraints they impose for the German context are carefully taken into account in the forthcoming Methods for Economic Evaluations for the German Statutory Health Care System produced by an International Committee of Experts on behalf of IQWiG. There, interested parties will find explicit, precise recommendations for each step of an economic evaluation intended to inform German decision-makers. Although the HCG states that the consensus “represents a rational approach for a structured resource allocation” and a “ ‘construction kit’ to standardize . . . applied methods,” they provide very little actual guidance on what ought to be done, limiting themselves instead to various lists of options—few specific to Germany—and the exhortation that the analyst justify the choice. They claim “to represent the framework for conducting health economic evaluation studies in Germany” but do not make the approach concrete, particularly in terms of bridging the gap between health economics and evidence-based medicine. It is undoubtedly difficult in such a short space to specify methods fully but many pronouncements are made with no indication as to how the lofty goals are to be met, not even references to where the reader might find the details. For example, HCG states that “Distributive and ethical problems and issues can be incorporated in the study if this is required” but leave the reader mystified as to how this very difficult aspect is to be accomplished. They suggest that if clinical studies have low external validity, they “. . . should be supplemented by high-quality health economic studies with greater external validity” but it remains unclear what specific methodological recommendation the HCG is making in this regard and they give no cluewhat criteria should be taken into account when making these judgments in practice. They propose that the analysis “may compare the approach in question with the most frequent, the clinically most effective or the most efficient alternative” but do not indicate which is to be preferred or why, much less how those rankings are to be established in the first place. We are told that “existing inefficiencies in the system and their cost effects also should be listed and discussed separately” with no hint of what these are, how they should be identified, or what is meant by their cost effects. Even when the guideline is concrete, many puzzling aspects remain. The HCG states that “priority should be given to the societal perspective” without justifying this for the German context or explaining how it is to be done. Truly after this demand would make it necessary to assess all consequences of an intervention not only throughout the health care system (including for teaching, research, employment, and so on) but also stretching beyond into other parts of the economy. This is obviously not a practical task and it is unclear to which actual decision-makers such a perspective would apply. It is said that “A marginal analysis should be performed to quantify the costs and outcomes of an additionally produced unit” but the grounds for doing this in Germany are not stipulated—particularly when it is also stated that “market procurement prices” should be used—“unit” is undefined as is what it means to “produce” one, and the baseline from which the margin is measured is not Address correspondence to: Peter L. Kolominsky-Rabas, Department of Health Economics, Institute for Quality and Efficiency in Health Care [IQWiG], Dillenburger Street 27, 51105 Koln, Germany. E-mail: peter.kolominsky-rabas@iqwig.de 10.1111/j.1524-4733.2008.00318.x Volume 11 • Number 4 • 2008 V A L U E I N H E A LT H

Full Text
Published version (Free)

Talk to us

Join us for a 30 min session where you can share your feedback and ask us any queries you have

Schedule a call