The criteria according to Lønning II
The severity criterion was relatively well described in Lønning II, but has not been equally well described in the above-mentioned Act and regulations. There has been some uncertainty with regard to how severity should influence priority setting in practice. One purpose of using severity of disease as a criterion is to place extra emphasis on those who are, or are expected to be, the least healthy. It is therefore a way of aiming to reduce health inequalities, and thus may be said to be based on the principle of equality, in this case related to equality of
outcome. For persons with life-threatening conditions (the top priority according to Lønning I), it is rather the principle of assistance for the most acutely ill (rule of rescue) (9) which is the underlying principle (4).
The criterion of efficacy of the intervention may be interpreted in different ways. The reason for possible confusion here is that in the Lønning II Commission’s recommendation, the second criterion is referred to as «the benefit of the intervention». Considering that in most places Lønning II refers to therapeutic effect (clinical outcome) as being the criterion that matters, the implication is probably that this is what they meant. So what is the problem with using «benefit» rather than «efficacy» – in everyday speech, is this not more or less the same thing? For economists, benefit is based on
valuation of the outcome. This can be achieved by measuring quality of life, for example. The Lønning II recommendation explicitly states that quality of life shall not be used as an indicator of clinical outcome because it was considered that the existing methods were not sufficiently mature to be used as an alternative to efficacy in practice. In other words, it appears unlikely that they intended us to use anything other than clinical efficacy as measured in randomised controlled trials.
Cost-effectiveness was a criterion which was introduced with the Lønning II Commission. The wording from 1997 has in no way lost its relevance: «Increased budgets do not necessarily make priority setting easier. Even with significant increases in resources, we have to undertake the same type of ranking and selection of those patients who should receive treatment. The principles will be the same, but the threshold for receiving treatment will be lower»
(5). In health economic evaluations, the idea is to weigh up the costs of an intervention against the effectiveness to see whether «the costs are reasonable compared to the effectiveness of the intervention» (6). The objective here is health maximisation; we want the best possible health for each Norwegian krone already allocated to the health budget. The proposed indicator for health in relation to cost-effectiveness in Lønning II is primarily quality and length of life. Quality Adjusted Life Years (QALYs) are an indicator which captures both the proposed dimensions, and it is probably this measure that the Commission had in mind. However, the Lønning II recommendation was somewhat unclear, and other objectives, for example (unadjusted) years of life, have also been used (10) and are even recommended as an alternative to QALYs in the Norwegian Directorate of Health’s guidelines for economic evaluations of health care (11).
The Lønning II Commission introduced the criterion of cost-effectiveness, but a long-standing problem has been the Commission’s failure to specify a
reasonable relationship between costs and effectiveness, that is, what is the cost-effectiveness threshold. Without this being specified, the criterion is difficult to apply in practice. In Figure 1 I have illustrated what we often refer to as the cost-effectiveness plane (12).
Figure 1 The cost-effectiveness plane. Health is measured on the x-axis and costs on the y-axis. The current treatment is the standard point of comparison, and is therefore placed in the centre (origin). Treatments with higher costs compared with existing treatments are placed above the x-axis and those with lower costs are placed below. Treatments to the left of the y-axis have lower effectiveness and those to the right have greater effectiveness. Treatments in the lower right quadrant are thus obviously cost-effective, and those in the upper left quadrant are obviously not cost-effective. In the remaining two quadrants of this plane we need the described threshold in order to know which treatments are cost-effective