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Coverage with evidence development, only in research, risk sharing or patient access scheme? A framework for coverage decisions

Listed author(s):
  • Simon Walker

    (Centre for Health Economics, University of York, UK)

  • Mark Sculpher

    (Centre for Health Economics, University of York, UK)

  • Karl Claxton

    (Centre for Health Economics, University of York, UK and Department of Economics and Related Studies, University of York, UK)

  • Steve Palmer

    (Centre for Health Economics, University of York, UK)

Registered author(s):

    Context Until recently, purchasers’ options regarding whether to pay for the use of technologies have been binary in nature: a treatment is covered or not covered. However, policies have emerged which expand the options - for example, linking coverage to evidence development, an option increasingly used for new treatments with limited/uncertain evidence. There has been little effort to reconcile the features of technologies with the available options in a way that reflects purchasers’ ranges of authority. Methods We developed a framework within which different options can be evaluated. We distinguished two sources of value in terms of health: the value of the technology per se; and the value of reducing decision uncertainty. The costs of reversing decisions are also considered. Findings Purchasers should weigh the expected benefits of coverage against the possibility the decision may need to be reversed and the possibility adoption will hinder/prevent evidence generation. Based on the purchaser’s range of authority and the features of the technology different decisions may be appropriate. The framework clarifies the assessments needed to establish the appropriateness of different decisions. A taxonomy of coverage decisions consistent with the framework is suggested. Conclusions A range of coverage options permit paying for use of promising medical technologies despite their limited/uncertain evidence bases. It is important that the option chosen be based upon not only the expected value of a technology but also the value of further research, the anticipated effect of coverage on further research, and the costs associated with reversing the decision.

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    File Function: First version, 2012
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    Paper provided by Centre for Health Economics, University of York in its series Working Papers with number 077cherp.

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    Length: pages
    Date of creation: Apr 2012
    Handle: RePEc:chy:respap:77cherp
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    1. Brazier, John & Ratcliffe, Julie & Salomon, Joshua & Tsuchiya, Aki, 2016. "Measuring and Valuing Health Benefits for Economic Evaluation," OUP Catalogue, Oxford University Press, edition 2, number 9780198725923.
    2. Claxton, Karl, 1999. "The irrelevance of inference: a decision-making approach to the stochastic evaluation of health care technologies," Journal of Health Economics, Elsevier, vol. 18(3), pages 341-364, June.
    3. Palmer, Stephen & Smith, Peter C., 2000. "Incorporating option values into the economic evaluation of health care technologies," Journal of Health Economics, Elsevier, vol. 19(5), pages 755-766, September.
    4. Martin, Stephen & Rice, Nigel & Smith, Peter C., 2008. "Does health care spending improve health outcomes? Evidence from English programme budgeting data," Journal of Health Economics, Elsevier, vol. 27(4), pages 826-842, July.
    5. Anders Anell & Ulf Persson, 2005. "Reimbursement and clinical guidance for pharmaceuticals in Sweden," The European Journal of Health Economics, Springer;Deutsche Gesellschaft für Gesundheitsökonomie (DGGÖ), vol. 6(3), pages 274-279, September.
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