Speaker Third Plenary Session SHOULD MULTI-CRITERIA DECISION ANALYSIS (MCDA) REPLACE COST EFFECTIVENESS ANALYSIS (CEA) FOR EVALUATION OF HEALTH CARE COVERAGE DECISIONS? Rob Baltussen, PhD Associate Professor, Health Economics, Nijmegen International Center for Health Systems Research and Education (NICHE) Radboud University Nijmegen Medical Center Nijmegen, The Netherlands Question is not whether but how to use MCDA Dr. Rob Baltussen Radboud University Nijmegen Medical Centre The Netherlands What is MCDA? • An aid to decision making which makes the impact of multiple criteria on decisions more explicit and the relative importance attached to them • Aims to improve • • • Quality of decisions by addressing relevant criteria Transparency and accountability of decisions Consistency of decisions Different approaches to MCDA • First steps are similar • establish panel, define criteria, assess interventions • Differences in interpretation performance matrix The use of MCDA • Many applications • • • • Individual level – shared decision making Local level – reallocation decisions (PBMA) National level – broad disease control priorities Approaches and tools: Evidem, 1000Minds • Can it be used for health care coverage decisions? • • First experiences (Thailand: Youngkong et al. Value in Health 2012) Now look at western countries Countries mention use of various criteria.. Criteria Australia Cost‐effectiveness Ѵ Budgetary impact Canada France Ѵ Ѵ Availability of alternative Ѵ Ѵ Ѵ Ѵ UK Ѵ Ѵ Ѵ Ѵ Ѵ Ѵ Affordability to individual Other... Netherlands Ѵ Severity Accessibility Danmark Ѵ … … … … … … Source: Adapted from Golan et al. Health Policy 2011 .. but these are often vaguely defined Criteria Australia Cost‐effectiveness Ѵ Budgetary impact Canada France Ѵ Ѵague Availability of alternative Ѵague Ѵague Ѵague Ѵague UK Ѵ Ѵ Ѵ Ѵ Ѵague Ѵague Affordability to individual Other… Netherlands Ѵague Severity Accessibility Danmark Ѵague … … Source: Adapted from Golan et al. Health Policy 2011 … … … … Can MCDA guide these decisions? • Current processes • strong focus on CEA • other criteria in process of deliberation – ‘afterthought’ • Challenges to application of MCDA • no broad consensus on what these criteria are • not all criteria are easily quantifiable Some good examples • UK – NICE: • • • threshold of £20,000 per QALY gained six special cases including ‘severity’ and ‘end of life’ threshold may then be £20,000 ‐ £30,000, or above • Netherlands • • €10,000 ‐ €80,000 per QALY gained, by ‘severity’ and other criteria • Elements of MCDA • criteria can be further defined? . MCDA for coverage decisions – a framework Has the technology special value because …. Relevance Yes / no Assessment Quantitative Qualitative Severity (……………………………) Key issue is then how to come to a decision End of life (..……………………….) • Option is to use ‘special’ CE treshold values for criteria Lack of alternative treatment Vulnerable group (……………..) Rare disease (…………………….) Intervention complexity (…..) Other …. Summary • MCDA holds potential to guide coverage decisions • May lead to better, more transparent and consistent decisions Should MCDA replace CEA? • MCDA not a mathematical solution for political problem • Unlikely to be full quantitative approach • • • • Yes it is already happening no consensus on all criteria not all criteria can be quantified deliberation always key Need to further develop MCDA…