The Paradigm Shift from Patient to Health Consumer: 25 Years of Value Assessment in Health
Date Submitted: May 14, 2024
Open Peer Review Period: May 17, 2024 - Jul 12, 2024
While economic analyses and health technology assessment have come a long way in their multi-faceted assessment of the clinical, economic, ethical, legal, and societal perspectives that may be impacted by a new technologies and procedures, these approaches do not reflect underlying patient preferences that may be important in the assessment of “value” in the current value-based healthcare revolution. Also, the arbitrary nature of the threshold in these studies limit a value-based approach to measuring dollars in terms if an increase in the QALY gained. The major challenges that come with the transformation to a value-based healthcare system lead to questions such as: “how are economic analyses, often the basis for policy and reimbursement decisions, going to switch from a societal to an individual perspective?”; and “how do we assess (economic) value, then, taking into account individual preference heterogeneity as well as varying heuristics and decision rules?” These challenges, both related to including the individual perspective in cost effectiveness analysis, have been widely debated. The societal perspective measures cost-effectiveness of treatment in terms of costs and Quality-Adjusted-Life-Years (QALY), where QALYs assume a health state that is more desirable is more valuable and, therefore, value is equated with preference or desirability. This approach has major empirical and conceptual shortcomings such as inconsistencies among values obtained from the standard-gamble, time-trade-off, and visual-analog-scale elicitation formats and more importantly, the linearity assumptions that violate the assumption of diminishing marginal utility. This paper reviews 25 years of value assessment approaches in health. It first describes the foundation of value assessment in other fields, then in the second part discusses the application of these methods in health economics. In the third part, it explains why value assessment works differently in health and a one-to-one copy from other fields in not always appropriate. It will be challenging to take into account the complexities of individual preferences and behaviors, especially if they are not met at the societal level. The paper does conclude with suggestions and opportunities to further improve value assessment methods in health in the years to come.