Amiram Gafni and Stephen Birch,1 in their excellent article on the importance of opportunity costs, posit that the uncontrolled growth in expenditures of the Ontario Drug Benefits Program (ODBP) is attributable to the use of the incremental cost-effectiveness ratio (ICER) of interventions, without consideration of opportunity costs, in the development of policy recommendations. The program's failure to control expenditures leads the authors to conclude that “simple tools such as the ICER represent a departure from the economics discipline and hence they fail to address the decision-makers' problems.”
While cost-effectiveness is indeed frequently misused, this particular conclusion does not seem justified. The real cause of the “uncontrolled growth in expenditures” of the ODBP is surely the belief of its administrators that their resources will, in fact, not be limited. That they are justified in this belief is evidenced by the fact that the government allows the program's expenditures to grow by 10% to 15%, year after year, as reported by Laupacis.2 Only if resources were limited and the program's budget fixed would it be necessary to consider opportunity costs. As long as administrators of the program are allowed to increase expenditures, it is entirely appropriate that they should try to get the best value for those resources by considering the ICER of each potential addition to the program. Indeed, it is the continuing failure of governments and their electors to forgo any health technology capable of bringing any benefit that is the real cause of the uncontrolled growth in expenditures.
Maurice McGregor Professor Emeritus Department of Medicine McGill University Montréal, Que.
References
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