Me­su­re des pré­fé­ren­ces / Dis­crete-Choice-Ex­pe­ri­ment

For years, it has been known that healthcare expenditure (HCE) spent during an individual's last year of life accounts for a high share of lifetime HCE (Lubitz and Riley, 1993; Riley and Lubitz, 2010). From the point of view of standard economics, this finding is puzzling because an investment in health is unlikely to have a sufficiently long payback period. However, Becker et al. (2007) and Philipson et al. (2010) have advanced a theory designed to explain high willingness to pay (WTP) for an extension of life close to its end. Their work has several empirically testable implications, which will be extended by using invoking the concept of 'pain of risk bearing' introduced by Eeckhoudt and Schlesinger (2006). This contribution seeks to test these implications using evidence from a Discrete Choice Experiment (DCE) performed in 2014, involving 1,529 Swiss adults. An individual setting where the price attribute is substantial out-of-pocket payment for a novel drug for treatment of terminal cancer is distinguished from a societal one, where it is an increase in contributions to social health insurance. Most of the economic predictions receive empirical support; however, estimated societal WTP may not exceed its individual counterpart, although there is evidence of both altruism and the effect of the public good characteristic of a therapy covered by social health insurance.

Wie viele medizinische Behandlungen vor dem Tod gibt es, die nur geringen Nutzen haben? Welchen Preis dürfen lebensverlängernde Massnahmen haben? Und was denkt die Schweizer Bevölkerung über Kosten und Wert von lebensverlängernden Massnahmen? Diesen schwierigen Fragen muss sich die Gesellschaft stellen. Zusammen mit der Universität Zürich und dem CSS Institut für empirische Gesundheitsökonomie untersuchen wir, ob die medizinischen Ressourcen am Lebensende optimal eingesetzt werden und ob die Gesellschaft eine Obergrenze für Kosten kurz vor dem Tod befürwortet bzw. wie hoch diese sein könnte. Link zur Publikation (NFP 67)

End-of-life costs are a substantial contributor to health care expenditures. Expensive new drugs with high costs per quality-adjusted life year (QALY) are widely discussed, but there is little information about the individual's willingness to pay (WTP) (both patients and members of the society) for such drugs. In this study, we elicit the preferences for end-of-life cancer treatments of the Swiss population. We conducted a discrete-choice experiment via an online survey with 1,527 representatively chosen Swiss individuals. The experiment was divided into two parts: an insurance setting (societal viewpoint) and a treatment setting (individual viewpoint). In the insurance setting, respondents had to choose between health insurance contracts with different coverage of cancer drugs for end-of-life treatments. In the treatment setting, respondents had to choose between different drugs from the perspective of a hypothetical end-stage cancer patient. In the insurance experiment, the individual marginal WTP amounts to 103 CHF of yearly insurance premium per additional month of survival time of cancer patients and 76 CHF to increase the quality of a patients’ life per 10 points (on a scale from 0 to 100). The societal mean WTP for a QALY amounts to 213,465 CHF for adult patients, 255,562 CHF for children and 153,590 CHF for elderly, respectively. In the treatment setting, the marginal WTP amounts to 3,686 CHF for an additional month of survival time and 8,965 CHF to increase the quality of life per 10 points. The mean WTP for a QALY amounts to 95,943 CHF. The WTP values vary considerably with regard to socio-demographic variables and affectedness, showing heterogeneous preferences in the Swiss population. The results show that the WTP for end-of-life treatments in Switzerland are high and lie above the common thresholds used by health technology agencies. WTP for a QALY is higher in the insurance setting, which might be due to solidarity or altruism. We can also see that a QALY is not a QALY. WTP for a QALY for children is about 65 percent higher than for the elderly.