Health Economics

Personal introduction! #

I have been putting off writing this entry for ages! Like a number of other entries that never seem to get to the top of the todo list I am sure it’s because it feels so hard to get a sensible summary. What I do with most similar topics, hm, probably with most entries, is to check what wikipedia says about the topic before wasting time doing my own if the wikipedia entry (or some other web resource) seems to cover it.

However, I think I’ve also been a bit blocked on this one as it takes me back to 1983/84 just before I went from general medicine to psychiatry and hence to psychotherapy and on to be the grumpy old man I am now! At the time I was going to go into what was then “community medicine”, now “public health medicine” (at least in the UK). A the time I can now see that Health Economics (HE) was still fairly young and one thing that was taking me to community medicine was concern that the NHS seemed to allocate resources so poorly, inefficiently, inequitably: all core HE issues. Fortunately or not, it took about three weeks for me to fall in love with mental health work, particularly psychotherapies, and here I am now 40 years later I guess I have worked on issues that touch back to HE ever since!

Details #

So HE is … the economics of health and healthcare systems or really the study of that: no surprises there! In fact the wikipedia entry is to my mind pretty good particularly on the history of the topic and some of the complexities though it’s very much written, as I suspect is much HE, with an American healthcare system in mind and perhaps surprisingly little on the economics of the NHS and non-insurance based publicly funded healthcare systems. I think it’s weak on many of the problems of modern technology/pharmacology driven, and finance market organised, healthcare.

For the purposes of a glossary mainly about mental health and well-being change measurement HE comes up in two ways:

  • estimates of “utility” via quality of life (QoL) that attempt to give us ways to compare the loss of quality of life across diverse problems (mental, physical and, arguably, holistic)
  • estimates of the costs of interventions and options for health and QoL improvement

In the horribly dominant paradigm of the large randomised controlled pitting two therapies against each other you will often see both involved and the cost-effectiveness of the interventions compared.

Utility is sometimes derived from a specific quality of life measure, perhaps most often the EQ-5D-5L or sometimes by converting scores on some or all items of another measure to utility values, using six items from the CORE-OM to get the CORE-6D utility values is the option I know best. There are enormous issues with both direct and indirect utility evaluation but I think we have to accept that it is better that people are grappling with the issues than that we ignore the challenges of optimising equity and effectiveness of diverse healthcare interventions.

Costs are easier! They are pretty much making sure that all the costs involved in provision of an intervention are estimated. Where appropriate (probably more often that we like to admit) “downstream” costs such as physical healthcare costs of self-harm are estimated. The estimation of costs to people other than the sufferer/client (mostly family but not only) are not often addressed that I have seen.

A bit tangential but important: the distributions of costs, particularly when downstream costs are included, are often very “long tailed” and positively skew, i.e. a few people have very high costs. As a result cost and cost effectiveness evaluations have been a particularly important area in which bootstrapping methods to estimate confidence intervals around observed values in studies have been vital.

Try also #

Bootstrap methods
Confidence intervals

Chapters #

We entirely dodged HE in the book!

Online resources #

Not yet.

Dates #

First created 30.iii.24.

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