Societal perspective in health-economic evaluations
Before any health-economic assessment, it is necessary to specify the evaluation perspective that should reflect the needs of intended recipients/decision makers. The chosen perspective defines the frame of analysis and determines the relevant cost structure. In health-economic analyses, the most commonly used perspectives are: (i) the payer perspective that includes only the costs and impacts on the specific payer predominantly from the healthcare sector whereas the payer may also be the patient and (ii) the societal perspective that covers all costs and effects of the intervention on the whole of society. Often, where patient is the payer it is referred to as the patient perspective.
The health care payer's perspective usually includes only direct medical costs, but the evaluated interventions often involve additional costs, direct non-medical costs, and indirect costs, that can significantly affect the patient or the economy as whole. The societal perspective, considering all these types of costs, is generally widely recommended for the offered complexity. But the theoretical consensus on the terminological and methodical frameworks is missing, and thus the conceptualizations and implementations of societal perspective vary considerably. In the literature, the societal perspective is mostly described via cost-of-illness studies (COI, i.e. total cost of illness) and cost-of-utility analysis (CUA, i.e. costs and effects of interventions).
The productivity loss (expressed through absenteeism and presenteeism) and intangible costs such as reduced quality of life of patients, their informal caregiver(s) or families, so called indirect costs, represent the huge burden of many serious chronical or orphan diseases. And although there is a general agreement in the literature that the inclusion of indirect costs into the pharmacoeconomic evaluation can significantly affect cost-effectiveness of evaluated interventions, this is only minimally applied in real practice. Picavet et al. found that only 11% of the CUA studies regarding orphan drugs included the societal perspective compared to 86% that applied the healthcare payer perspective (1). Similar results were reported in the review summarizing the economic evaluation of selected expensive drugs, where only about 9% of the papers included the costs related to productivity loss (2). Moreover, the recommendation for including these resources remains out of most of the national guidelines. But the direction of decision-makers in some countries such as France, Sweden or The Netherlands is already moving towards the evaluation of the societal perspective, there are official recommendations for the usage of the societal perspective in the economic evaluation of health interventions. Other countries recommend using both the health payer and the societal perspective, for example the Czech Republic, where the Amendment to Act No. 48/1997 Coll., on Public Health Insurance, in force since January 2022, introduces a special procedure for orphan drugs. Among other things the Act defines the criteria through the lens of which the application for reimbursement of orphan drugs should be assessed including societal perspective and government perspective.
In CEEOR we apply the updated internationally recognised CHEERS standards (The Consolidated Health Economic Evaluation Reporting Standards) (3). To adjust it to a national requirement as well as specific characteristics remains one of the everlasting challenges.
(1) Picavet E, Cassiman D, Simoens S. What is known about the cost-effectiveness of orphan drugs? Evidence from cost-utility analyses. J Clin Pharm Ther. 2015 Jun;40(3):304-7. doi: 10.1111/jcpt.12271. Epub 2015 Apr 20. PMID: 25891411.
(2) Krol M, Papenburg J, Tan SS, Brouwer W, Hakkaart L. A noticeable difference? Productivity costs related to paid and unpaid work in economic evaluations on expensive drugs. Eur J Health Econ. 2016 May;17(4):391-402. doi: 10.1007/s10198-015-0685-x. Epub 2015 Apr 16. PMID: 25876834; PMCID: PMC4837201.
(3) Husereau, D., Drummond, M., Augustovski, F. et al. Consolidated Health Economic Evaluation Reporting Standards 2022 (CHEERS 2022) statement: updated reporting guidance for health economic evaluations. BMC Med 20, 23 (2022). https://doi.org/10.1186/s12916-021-02204-0.