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WHY COSTING INTERVENTIONS IS IMPORTANT

A variety of factors has transpired to bring the economic evaluation of behavioral interventions to the forefront of analytic considerations. One primary reason is the reorganization of health care. In the United States, the health care marketplace is increasingly cost conscious, with system-level initiatives being implemented to improve health care value. In this context, “value” is defined by interventions that achieve desired patient outcomes at a cost lower than the current standard of care, or interventions that achieve better outcomes than the standard of care but cost more. It is no longer sufficient to accept treatment just on the basis of an efficacy trial and positive outcomes alone. At a minimum, a treatment must also have demonstrated value. This change in focus to value presents a challenge for behavioral intervention researchers. The challenge is that the evidence necessary for adopting a behavioral intervention has been expanded from efficacy and effectiveness (demonstrated against a control group) to also include comparative effectiveness (demonstrated vs. a usual care comparison) and cost-effectiveness.

It could be argued that, given these contextual factors, economic evaluations are relevant for any intervention whether it be medical, drug, or behavioral. Yet, economic evaluations of behavioral interventions are particularly important since traditional medical approaches (e.g., pharmaceuticals) may have limited effectiveness and/or be contraindicated—and cannot address alone the array of major public health concerns such as mental illness, health disparities, obesity, and disabilities (see Chapter 1). In addition, medical approaches alone may result in negative consequences such as polypharmacy and medication-related problems. Added to this, the aging of the population is resulting in an increase in persons with physical, cognitive, or financial limitations or complex health conditions that need ongoing self-care management. Behavioral strategies have the potential to address these issues, thereby meeting an urgent and growing population health need.

Nevertheless, there is little evidence about what behavioral interventions actually cost and what their value is compared to traditional practices. In order for behavioral interventions to be adopted, health care decision makers from both government and private health care payers (particularly health plans), as well as health care providers, will need credible information about the costs of these interventions in terms of the human and nonhuman resources required for training persons and delivering these programs. Unlike traditional medical approaches where the price is set by the innovator, behavioral interventions often do not have a clear market established and/or enter the marketplace without having an established price or reimbursement mechanism. Therefore, behavioral researchers must be proactive in measuring costs, for example, by embedding cost measures during the efficacy and

TABLE 18.1 Key Terms

Term

Definition

Source

Value

A balance of economic, humanistic, and clinical outcomes

Dipiro et al. (2011)

Adopter

The person or institution who decides whether to invest in a new treatment alternative

Dearing (2009)

Perspective

The point of view taken (i.e., participant, provider, payer, or society) when determining the value of a treatment alternative

Dipiro et al. (2011)

Societal

perspective

The broadest perspective of an economic evaluation that considers the benefits to society as a whole and includes both direct (health care) and indirect (non-health care) costs

Dipiro et al. (2011)

Piggybacking

The term used to describe an economic study that is added onto a clinical trial that originally focused on clinical issues

Berger, Bingefors, Hedblom, Pashos, and Torrance (2003)

Prospective

studies

Studies that involve the collection of data on endpoints, treatments, and related measures forward in time

Berger et al. (2003)

Economic

model

A simplified framework that mathematically represents a population, with outputs (e.g., effectiveness measures) that respond to changes in inputs (e.g., participant characteristics) in a realistic way

Berger et al. (2003)

Retrospective

studies

Studies that analyze outcomes on the basis of currently available data and are typically collected from medical claims, electronic medical records, hospital discharge data, and managed care encounter data

Berger et al. (2003)

Economic

evaluations

An evaluation that compares the costs of two or more alternatives without regard to outcome

Dipiro et al. (2011)

Partial economic evaluations

See "Economic Evaluations"

Cost-

minimization

studies

Evaluations comparing two or more treatment alternatives with an assumed or demonstrated equivalence in safety and efficacy to determine the least costly alternative

Dipiro et al. (2011)

Return-on-

investment

studies

Studies that examine the health care investments made, in relation to financial savings

Authors

Cost-of-illness

studies

Evaluations that identify and estimate the overall cost of a particular disease for a defined population by measuring the direct and indirect costs attributable to the specific disease

Dipiro et al. (2011)

TABLE 18.1 Key Terms (Continued)

Term

Definition

Source

Cost-

effectiveness

analysis

A systematic method of comparing two or more alternative programs by measuring the costs and consequences of each

Berger et al. (2003)

Incremental

cost-

effectiveness ratio (ICER)

The difference between program costs divided by the difference between program outcomes

Berger et al. (2003)

Cost-utility

analysis

A method for comparing two or more treatment alternatives in terms of both costs and outcomes that integrates participant preferences and utility

Dipiro et al. (2011)

Quality- adjusted life years (QALYs)

A universal measure of disease burden (including quality and quantity of life) applicable to all individuals and all diseases

Berger et al. (2003)

Cost-benefit

analysis

An evaluation that allows for the identification, measurement, and comparison of the costs to provide a program or treatment alternative and the benefits to be realized from it

Dipiro et al. (2011)

Intervention

costs

The expenses that are required to implement an intervention. Examples of intervention costs include materials/supplies, personnel training, and personnel time delivering intervention

Authors

Health care costs

The costs incurred for medical products and services used to prevent, detect, and/ or treat a disease. Examples include but are not limited to medications, medical supplies, hospitalizations, and physician visits

Dipiro et al. (2011)

Non-health care costs

Costs for nonmedical services (e.g., transportation or childcare) and reduced work productivity that result from illness/disease

Dipiro et al. (2011)

Gross costing

A method of collecting cost data by using cost estimates for units of input or output that are large relative to the intervention being analyzed

Gold et al. (1996)

Microcosting

A method of collecting cost data that calls for the "direct enumeration and costing out of every input consumed in the treatment of a particular participant" (Gold et al., 1996). Examples of microcosting include documenting personnel time to complete tasks, or collecting travel data of participants or personnel

Gold et al. (1996)

Health status questionnaires

Survey instruments used to assess participant outcomes. Examples commonly used in economic evaluation include quality-adjusted life, productivity, functional status

Authors

TABLE 18.1 Key Terms (Continued)_

Term

Definition

Source

Preference-

based

quality-of-life

weights

A degree of preference individuals or society has for living in a particular health state or condition. Weights typically vary between 0 (interpreted as "deceased") and 1 (interpreted as "perfect health")

Neumann, Goldie, and Weinstein (2000)

Health utility

Refers to the preferences individuals or society place on any specific health outcome relative to other possible outcomes

Pizzi and Lofland (2006)

Sensitivity

analysis

A way to analyze the impact of uncertainty on an economic evaluation or decision

Berger et al. (2003)

One-way sensitivity analysis

The simplest form of sensitivity analysis by which the value of one variable is varied within a range of plausible values while the other variables are kept constant

Berger et al. (2003)

Threshold

analysis

A method of investigating the impact of uncertainty upon payoffs and decisions by identifying the levels of one or more parameters, assumptions, or methods at which the decision switches

Berger et al. (2003)

Two-way sensitivity analysis

A form of sensitivity analysis by which the value of two variables are varied within a range of plausible values while the other variables are kept constant

Berger et al. (2003)

Probabilistic sensitivity analysis

A method of investigating the impact of uncertainty in all parameters simultaneously, assuming that each parameter has a range of possible values

Wang, Salmon, and Walton (2004)

Base case

In reference to a cost model, the expected case of a model using an initial set of assumptions

Authors

Statement of benefits

Statement sent by the health plan explaining what medical treatments and/or services were paid

"Glossary" (2015)

Out-of-pocket

costs

The portion of a payment paid for by an individual with his or her own money (copayments and deductibles) as opposed to the portion paid for by the insurer

Berger et al. (2003)

effectiveness phases of research, or possibly before when demonstrating proof of concept as part of a Phase II study. It is only when the cost of the intervention is established that it can be examined in relation to its effectiveness.

 
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