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Cost-benefit and cost-effectiveness analysis: applications to health care programs and policies . Greg Mason PRA Inc. and University of Manitoba October 28, 2011. Value for money Value for money (VFM)is the priority activity in public and private health policy.
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Cost-benefit andcost-effectiveness analysis: applications to health care programs and policies Greg Mason PRA Inc. and University of Manitoba October 28, 2011
Value for money • Value for money (VFM)is the priority activity in public and private health policy. • VFM = “bang per buck” or “buck per bang” • VFM = [benefits – cost] = net benefits • Key questions: • Do the benefits exceed the costs? • What set of programs, interventions, and policies produce the greatest set of net benefits? • What are the bad (negative VFM) ideas? • Techniques from economics such as cost-effectiveness and cost-benefit offer useful tools for identifying and ranking VFM in health programs and policy.
Value for money • Are we doing the right thing? Relevance • Are we doing it well? Performance
Value for money: relevance • Relevance issues: • Issue 1 - Continued need for the program: Assessment of the extent to which the program meets a demonstrable need and is responsive to the needs of Canadians. • Issue 2 - Alignment with payer/user/provider priorities: Assessment of the linkages between program objectives and (i) federal government priorities and (ii) departmental strategic outcomes. • Issue 3 - Alignment with payer roles and responsibilities: Assessment of the roles and responsibilities of the payer in delivering the program. Source: Adapted from Treasury Board of Canada, Directive on the Evaluation Function (Annex A) April 2009
Value for money: performance • Performance issues (effectiveness, efficiency, and economy) • Issue 4 - Achievement of expected outcomes: Outcomes achieved (including immediate, intermediate, and ultimate outcomes). • Issue 5 - Demonstration of efficiency and economy: Assessment of resource utilization (cost) in relation to the production of outputs and progress needed to realize expected outcomes. Source: Adapted from Treasury Board of Canada, Directive on the Evaluation Function (Annex A) April 2009
Immediate Longer-term Activities Outputs outcomes outcomes (Typically within a year) (Up to 15 years) Economy Efficiency Effectiveness Cost to complete activities Cost per nursetrained Cost per client that becomes employed (e.g., total training costs (e.g., cost of recruitment, (e.g., total program costs divided by course development) divided by graduates) number of patients that achieve a specific health outcome) Performance is measured along the results chain
Economy reflects the unit cost of engaging in activities, such as trainee assessment, case planning for clients, or creating and managing a clinic. Example: Cost of developing courseware (wages + overhead + materials) Example: Cost of setting up flu clinics (location, staff training, media, notifying vulnerable groups)
Efficiency is the unit cost of all the activities needed to produce and output. Example: Cost per nurse graduate (number of grads divided by the total program cost) Example: Cost per potential flu shot (before any shots are actually given) Example: Cost of awarding a dollar to third party delivery for screening program
Effectiveness (also termed cost-effectiveness) is the cost of obtaining one unit of outcome. • Example: • Number of flu shots (immediate) • Reduction in the incidence of flu as a result of a vaccination promotion program (longer term) • Example: • Increase in screening incidence (short term) • Increase in five-year survival rate for Stage 2 breast cancers (long term)
Application of result chain analysis:the logic model The “logic model” is the core tool for conceptualizing causal relationships between program interventions and outcomes. • Health screening using third party delivery (e.g., diabetes screening in First Nation communities) • Electronic medical records to improve service delivery by providers (currently in primary care clinical settings)
Structure of vaccination CEA • Benefit • reduced short-term cost due to illness • reduced long-term cost for caring for the small number of catastrophic incidents • averted loss of incomes for those who are disabled/dying • averted cost of lost time at work and play • Cost • economic loss for the small number who experience adverse reactions to vaccine • vaccination program
Cost-effectiveness analysis example –vaccination programs for at-risk groups • Outputs include the creation of vaccination sites or alternative delivery (e.g., pharmacies, places of work, physician offices, shopping malls). • Outcomes include: • the numbers vaccinated • reduction in sick days • avoided deaths • The delivery approach with the lowest cost of organizing per potential vaccination delivered is the most cost-effective in terms of outputs. • The delivery approach with the lowest number of sick days per dollar cost is the most cost-effective in terms of outcomes.
Vaccination for measles(Axnick et al., 1969) Axnick, N.W., Shavell, S.M., and Witte, J.J.,(1969). Benefits Due to Immunization Against Measles, Public Health Reports , Vol. 84, No. 8.
