We address two criticisms of valuing patient and carer time in HTA: that it would displace health outcomes by misallocating a fixed budget, and that it would introduce inequities based on individual productivity or income. We argue that patient and carer time are vital inputs to healthcare, and that ignoring them reduces rather than improves both efficiency and fairness.
Debates about the equity implications of adopting a broader perspective on value in Health Technology Assessment (HTA) have reignited since the publications of the Health Economics Methods Advisory (HEMA) report. HEMA acknowledges, in principle, the relevance of broader value elements like time missed from work or school, and the broader effects of ill health on the work and the economy when appraising the value of a health technology. OHE has contributed to this debate with its own Whitepaper arguing for a broader perspective on value.
The debate
A key debate centres on whether HTA should consider how a new health technology changes how people (especially patients and carers) can use their time when appraising the value of that technology.
The argument for such consideration is that people’s time is scarce and valuable, and technologies that let someone spend more of their time as they would choose has additional value relative to technologies that require them to spend their time receiving treatment or looking after someone as an unpaid carer. Imagine, for example, moving from treatment via an infusion administered as an outpatient to an oral tablet that can be taken at home. The new treatment allows the patient and the carer to spend less time travelling back and forth between hospital, and more time as they would choose. Consideration of the value of a patient’s or a carer’s time in this context would assign additional value to the oral treatment, even if the final health outcomes are the same.
The primary arguments against such consideration are that, 1) it moves HTA towards valuing treatments on the basis of how they are delivered, in addition to the health outcomes they achieve, with important health opportunity cost implications, and 2) valuing people’s time could unfairly prioritise patients based on their productivity or their income rather than their health needs or capacity to benefit from treatment, introducing or reinforcing structural inequities.
Patient and carer time are inputs to healthcare
With respect to the argument that valuing time inappropriately moves HTA towards valuing how a treatment is delivered rather than its effect on health outcomes, it would seem intuitive and relatively uncontroversial that a treatment that requires patients and carers to spend less time travelling or receiving treatment has more value than an otherwise equal treatment that consumes more of a patient’s time, for the same health outcome. There is, however, the matter of opportunity cost: under a fixed healthcare budget, spending more for a treatment that gains one patient time could displace another patient’s health. Such uncomfortable opportunity costs are, of course, the unescapable reality of a fixed budget. It is critical to recognise, though, that there is also an opportunity cost to patient time, and indeed, that patient and carer time are inputs to healthcare just as much as physician and nursing time. As such, trade-offs between time and health are no different from trade-offs between money and health. Likewise, if we can accept forgoing some health outcomes on the basis of physician or nursing time, we should be able to accept foregoing some health outcomes on the basis of patient and carer time. HTA should value the full range of inputs to healthcare rather than simply refusing to acknowledge some trade-offs and opportunity costs.
Valuing time does not mean valuing productivity
With respect to arguments that valuing patient and carer time would introduce or reinforce structural inequities, these misunderstand or misrepresent how the value of people’s time could be incorporated into an appraisal of a new technology.
First, these arguments conflate concern for people’s time and people’s productivity. This reflects a conventional human capital approach to valuing patient and carer time, but these are fundamentally different concepts. As noted, concern for someone’s time in the context of HTA means assigning greater value to a treatment that allows an individual to spend more of their time as they would choose. This represents a move beyond consideration of strictly health-related outcomes and towards a ‘broader’ concept of patient and carer wellbeing.
Concern for someone’s productivity, on the other hand, means valuing treatments that improve someone’s ability to contribute to economic activity. Value in this context is less about people using their time however they might choose, and specifically about their ability to generate revenue. Greater economic activity generates greater tax or social security revenues, which in turn, finance publicly-funded healthcare. Valuing productivity means, in effect, valuing the ability of individuals to indirectly contribute to the cost of their care (and the care of others in society).
Time and productivity are both valuable in their own way, but they are not the same thing. Concern for someone’s time means valuing someone’s time however they choose to use it; concern for someone’s productivity means valuing a specific use of their time. Critically, we are able to value someone’s time without needing to value that time in terms of their individual productivity. We, as a society, could assign a single, universal value to the ability of a patient or a carer to use an hour or a day of their time as they choose, in the same manner in which we have put an implicit or explicit societal value on health. This could be through contingent valuation, or simply by valuing everyone’s time at an average wage, in the same way we assign cohorts in an economic model an average health state utility or average life expectancy.
Second, it extends the misunderstanding that valuing time must imply valuing productivity to suggest that HTA somehow compares the value of the same treatment to different patients, in a way that would favour those with greater productivity (i.e. income). But this is not how HTA is applied. HTA compares the value of different treatments to the same patients. That is, HTA compares the costs and health outcomes of different treatments in hypothetical cohorts, where each cohort is identical except for the treatment they receive. In this ‘counterfactual’ approach, there is no opportunity for individual differences in income or socioeconomic status between patients to influence the value of different treatments, as the distribution of these characteristics is identical across all the cohorts.
That said, different diseases may be more likely to affect specific sociodemographic groups. Think, for example, of Alzheimer’s disease affecting predominantly older, retired persons versus breast cancer affecting younger, working-age women. The ‘time equals productivity’ argument, reflecting a ‘human capital’ approach to policy analysis, would imply that there is more societal value to treating breast cancer than Alzheimer’s disease, as breast cancer patients will be more likely to return to employment following treatment, generating greater economic activity and tax revenues. This could make it easier for breast cancer treatments to meet an acceptable cost per QALY value threshold than Alzheimer’s treatments, introducing the potential for discrimination between diseases on the basis of the productivity of those affected, favouring already advantaged socioeconomic groups. Reinforcing structural inequity is arguably the main reason HTA bodies have consistently chosen not to value productivity in its appraisals. However, valuing the time of patients living with Alzheimer’s or breast cancer does not introduce an inequity if we value that time at the same rate for all patients. This small but important departure from a productivity-focused human capital approach removes the primary equity objection to considering the value of a patient’s time while allowing society to recognise the value of time-saving treatments.
Finally, there is the inescapable Law of Unintended Consequences. Ignoring the value of a patient or carer’s time out of concern for one potential (but avoidable) inequity based around relative productivity introduces other potential inequities, including around access to care. Not recognising the additional value of the oral treatment could block its HTA recommendation, leaving patients having to travel long-distances to hospital for the infusion. This will be easier for some patients than others, leading to inequities in access to treatment, adherence, and health outcomes based on geography, employment status, or yes, productivity and income.
Valuing patient and carer time leads to, not prevents, fair and efficient allocations
Adopting a blinkered perspective on value and simply ignoring some inputs to the healthcare production function will not lead to a fair and efficient allocation of resources. Likewise, it will not eliminate inequities in access to treatments based on productivity and is likely to introduce others. Rather, a fair and efficient allocation of resources, as well as a patient-centred healthcare system, requires appropriate recognition of the value of patient and carer time.