Download Cost - King`s College London

Current activities:
•
Director of PSSRU
•
Director of LSE Health
•
Professor, health economics KCL
•
Director of NIHR SSCR
Current research areas:
•
Depression, psychosis
•
Dementia
•
Stroke
•
Telehealth/telecare
•
Long-term (social) care
•
Child mental health; wellbeing
•
Genetic testing (economics of)
•
Autism
•
Intellectual disability
•
Carers
London School of Economics
and Political Science
•
Community of
capital
building
King’s College London,
Institute
Psychiatry
•
Prevention
NIHR School for •Social
Care Research
Inequalities
Mental health
and economics
Martin Knapp
Mental
health
Prevalence of mental health problems
– working age population (UK)
100%
80%
60%
40%
20%
0%
Symptom-free  64%
Severe mental illness
(schizophrenia, bipolar disorder,
serious depression)  1%-2%
Common mental disorders:
symptoms that reach threshold for
diagnosis  17%
Symptoms (sleep problems, fatigue,
worry, but no disorder  17%
Years lost to disability (men) - globally
All Causes
Total YLD (millions)
% of total
1. Unipolar major depression
20.35
7.7
2. Hearing Loss, adult onset
14.96
5.6
3. Cataracts
12.16
4.6
4. Alcohol use
11.5
4.3
5. Cerebrovascular disease
7.58
3.1
6. Vision related disorders
7.23
2.7
7. Peri-natal conditions
7.03
2.7
8. Osteoarthritis
6.59
2.5
9. Chronic Obstructive Pulmonary
Disorder
6.55
2.5
10. Schizophrenia
5.66
2.1
Disease Control Priority Project 2006,
Years lost to disability (women)
All Causes
Total YLD (millions)
% of total
1. Unipolar major depression
31.26
11.0
2. Cataracts
16.49
5.8
3. Hearing Loss
15.03
5.3
4. Osteoarthritis
10.83
3.8
5. Vision related disorders
9.66
3.4
6. Alzheimers & other dementia
9.46
3.3
7. Cerebrovascular disease
6.98
2.5
8. Perinatal conditions
6.91
2.4
9. Schizophrenia
5.58
2.0
10. Bi-Polar Disorder
4.82
1.7
Disease Control Priority Project 2006,
Current & projected future prevalence
N of people by disorder, England 2007 & 2026
Number of people (million)
3
2.56
2.47
2.64
2.28
2
1.45
1.24
1.14
1.23
0.94
1
0.61
0.21
0.24
0.69
0.58
0.117 0.122
0
DEP
ANX
SCH
BPD
EAT
PER
CHI
DEM
McCrone, Dhanasiri, Patel, Knapp, Lawton-Smith, Paying the Price, King’s Fund, 2008
Projected number of people with
dementia in the UK: 2005-2029
1200000
Source: Knapp et al (2007)
Dementia UK report
1000000
600000
400000
200000
0
20
0
20 5
0
20 6
0
20 7
0
20 8
0
20 9
1
20 0
1
20 1
1
20 2
1
20 3
1
20 4
1
20 5
1
20 6
1
20 7
1
20 8
1
20 9
2
20 0
2
20 1
2
20 2
2
20 3
2
20 4
2
20 5
2
20 6
2
20 7
2
20 8
29
Number of people
800000
100 & over
95-99
90-94
85-89
80-84
75-79
70-74
65-69
Characteristics of mental health …
o
o
o
o
o
o
o
o
o
o
o
High prevalence
Chronic course
Genes / environment
Multiple needs
Employment effects
Links to suicide / self-harm
Compulsory treatment / detention
Stigma & discrimination
Family impacts
Antisocial behaviour, crime
Mental well-being / happiness
… with economic consequences
o
o
o
o
o
o
o
o
o
o
o
High prevalence  high expenditure
Chronic course  lifelong economic impacts
Genes/environment  complex causality
Multiple needs  wide-ranging costs
Employment effects  productivity losses
Links to suicide/self-harm  fear/costs etc
Compulsory treatment  user choice?
Stigma & discrimination  social exclusion
Family impacts  often hidden; incentives?
Crime  exaggerated societal reactions?
Mental well-being  links to happiness
Leading mental health policy themes
a.
Wider NHS and social care structures - financing; commissioning;
competition … few MH-specific issues.
b.
Coordination - getting health and other systems to work together
more effectively and efficiently
c.
Prevention of mental illness; and promotion of mental wellbeing.
d.
Early intervention – life-course perspectives etc
e.
Roles of hospitals (and other institutions) - appropriate housing
support; community care
f.
Personalisation – responding to individual needs and preferences;
hence personal budgets etc
e.
f.
g.
h.
Employment, including welfare payments, absenteeism, presenteeism
Social inclusion – rights, opportunities, participation etc
Equity – vicious cycle linking deprivation to morbidity
Ageing and implications for not just dementia but also psychoses,
depression
Stigma and discrimination (at the root of many challenges?)
i.
Economic
questions
Example: Treatments for depression …
Interventions
Antidepressant
medication
CBT
Primary care
counselling
Interpersonal
psychotherapy
Couple therapy
… could lead to better outcomes …
Interventions
Outcomes
Antidepressant
medication
Symptom
alleviation
CBT
Interpersonal
functioning
Primary care
counselling
Interpersonal
psychotherapy
Couple therapy
Social functioning
Employment
Quality of life
… and lower longer-term costs.
Interventions
Outcomes
Antidepressant
medication
Symptom
alleviation
CBT
Interpersonal
functioning
Primary care
counselling
Interpersonal
psychotherapy
Couple therapy
Social functioning
Employment
Quality of life
Cost savings
Lower use of
health and social
care services
Fewer out-ofpocket expenses
Greater economic
productivity
Higher income
Question 1: What does it cost?
Interventions
Outcomes
Antidepressant
medication
Symptom
alleviation
CBT
Interpersonal
functioning
Primary care
counselling
Interpersonal
psychotherapy
Couple therapy
Social functioning
Employment
Quality of life
Cost savings
Lower use of
health and social
care services
Fewer out-ofpocket expenses
Greater economic
productivity
Higher income
Question 2: Will it pay for itself?
Interventions
Outcomes
Antidepressant
medication
Symptom
alleviation
CBT
Interpersonal
functioning
Primary care
counselling
Interpersonal
psychotherapy
Couple therapy
Social functioning
Employment
Quality of life
Cost savings
Lower use of
health and social
care services
Fewer out-ofpocket expenses
Greater economic
productivity
Higher income
Question 3: Is it worth it?
Interventions
Outcomes
Antidepressant
medication
Symptom
alleviation
CBT
Interpersonal
functioning
Primary care
counselling
Interpersonal
psychotherapy
Couple therapy
Social functioning
Employment
Quality of life
Cost savings
Lower use of
health and social
care services
Fewer out-ofpocket expenses
Greater economic
productivity
Higher income
4. Incentives
?
Question 4: Can
we change
things?
Interventions
Outcomes
4. Incentives?
Antidepressant
medication
Symptom
alleviation
CBT
Interpersonal
functioning
Primary care
counselling
Interpersonal
psychotherapy
Couple therapy
Social functioning
Employment
Quality of life
Cost savings
Lower use of
health and social
care services
Fewer out-ofpocket expenses
Greater economic
productivity
Higher income
Costs
Many causes; widespread impacts
Genes
Health care
Family
Social care
Income
Housing
Emply’t
Resilience
Longterm
needs
Education
Crim justice
Trauma
Benefits
Phys env
Employment
Events
Vol sector
Chance
Income
Mortality
…on many different budgets (England)
Genes
Health care
NHS
Family
Social care
Income
Housing
LAs
CLG
Education
DfE
Crim justice
MoJ
Trauma
Benefits
DWP
Phys env
Employment
Firms
Events
Vol sector
CVOs
Chance
Income
Indiv
Mortality
All
Emply’t
Resilience
Longterm
needs
Expenditure projections for people
with dementia 2002 to 2031
Projected total LTC
expenditure, at 2002 prices
LTC expenditure as % of
Gross Domestic Product
Red – older people with cognitive impairment; Blue - not
2.5
40
2
30
1.5
20
1
10
0.5
0
0
2002
2031
Comas-Herrera et al, IJGP 2007
2002
2031
Depression – costs for adults in
England, 2000
Mortality
61%
Excluding
‘morbidity’
costs
Out-patient
2%
Day care
0%
In-patient
3%
Thomas & Morris Brit J Psychiatry 2003
General
practitioner
1%
Primary care
medication
33%
Depression – costs for adults in
England, 2000 - continued
Total cost = £9 bn
Productivity
90%
Mortality
6%
Service costs
4%
Thomas & Morris Brit J Psychiatry 2003
GB - employment and mental health
60
GB 2000
% in full-time work
40
20
0
Moderate
depression
Mild
depression
OCD
GAD
Schizophrenia No psychiatric
problems
GB - disability benefits, 2007
22%
6%
€ 3.9 billion per annum
18%
Plus reduced tax receipts €14 billion
40%
8%
6%
Other
Mental and Behavioural Disorders
Nervous System
Circulatory and Respiratory System
Musculoskeletal System
Injury, Poisoning, External Causes
Department of Work and Pensions, 2007
Costs of health service use by diabetes
patients, by depression severity
0
1
2
3
Number of reported diabetes complications
10000
8000
6000
4000
2000
0
0
1
2
No depression
3
0
1
2
3
Subthreshold depression
Simon et al, Gen Hosp Psychiatry, 2005
0
1
2
3
Major depression
Costs - young children with persistent
antisocial behaviour
Health care
5%
Social care
0%
Education
5%
Voluntary
2%
Benefits
43%
Family costs
45%
Total cost excluding benefits averaged £5,960 per
child per year, at 2000/01 prices (benefits = £4307)
Romeo, Knapp, Scott (2009). Children with antisocial behaviour. British J Psychiatry 188: 547-533
Evidence from the Inner London
Longitudinal Study




All 10-year olds in a London borough, 1970
(n=1689). Led by Michael Rutter at that time
Teacher ratings, child questionnaires
Intensively studied 50% of children with
psychological problems and random 8% of others
At age 10:
•
•
•
•
•
No problems at school, no clinical diagnosis (65)
Antisocial behaviour at school, only (61)
Conduct disorder (16)
Emotional problems at school, only (32)
Emotional disorder (8)

Followed up at age 26-28 …
Research question: What services were used and
what costs incurred between aged 10 and 28?
Costs in early adulthood linked to
childhood antisocial behaviour
60000
Criminal
justice
justice
Benefits
Benefits
Relationships
Relationships
Costs (£)
from ages
10 to 28
40000
40000
Social care
care
Social
Health
Health
20000
20000
Education
Education
0
0
No problems
No problems
Conduct
Conduct
Conduct
Conduct
problems
disorder
problems
disorder
Scott, Knapp, Henderson, Maughan (2001) Financial cost of social exclusion: followup study of antisocial children into adulthood. Brit Med J 323: 191-4.
Cost-offsets
New economic
evidence on
mental health
promotion and
mental illness
prevention
Check report for
full details
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_126085
Our approach - 1
Aim - model the costs and economic pay-offs of initiatives to
prevent mental illness and promote mental well-being.
o
Looked at evidence-based mental health interventions
(incl. non-NHS) – must have well-established outcomes
o
Looked at 15 different areas and interventions
o
Used simple decision analytic modelling
o
Close liaison with DH officials; consultation with experts
As far as the robust evidence base allows:
o
Included promotion, primary, secondary prevention
o
Looked at widest range of economic impacts
o
Estimated impacts over long time periods
o
If in doubt, we adopted conservative estimates
Our approach - 2
o
Examined interventions from 2 perspectives:
- pay-offs to society as a whole and
- cash savings to the public sector
o
And interested particularly in the timing of impacts and
whether (or when) ‘cashable’
o
Over and above the economic pay-offs there are health and
QOL benefits to individual patients
Important to note that …
a.
These are simple, partial and incomplete models
b.
Findings are not definitive: they provide a platform for
discussion (hence publication on DH website and linked
elsewhere)
c.
Interventions modelled are not necessarily the only ones that
are economically attractive
d.
BUT every intervention has ‘proven’ health/wellbeing benefits
Debt: mental health challenges
Prevalence of mental health problems
• 45% of people in debt have mental health problems
compared with 14% not in debt
Incidence of mental health problems
• Developing unmanageable debt is associated with an
8.4% risk of mental health problems compared to
6.3% for people without financial problems
Specific conditions
• Alcoholism (2x), Drug Addition (4x), Suicidal ideation
(2x)
Source: Fitch et al, submitted; Meltzer, et al., 2010; Skapinakis et al., 2006;
Debt counselling: the economic case
Target
General population without mental health problems who
are at risk of unmanageable debt
Intervention
Debt advice services, provided on face-to-face,
telephone or internet basis
Outcome
evidence
Unmanageable debt increases risk of developing
depression/anxiety disorders by 2% in general
population. Face-to-face service alleviates 56% of
unmanageable debt; telephone service alleviates 47%.
Economic
pay-offs
Reductions in: health and social care service use; lost
employment; legal system costs; costs to local economy
Findings
Complicated …! Savings depend on who pays, mode of
delivery, and amount of debt recovered. Telephone/web
advice cost saving (most scenarios). Face-to-face advice
most cost-effective. If 2/3 of service costs recovered
from creditors, then total savings = £0.63 per £1
invested in first year; and £3.55 over 5 years.
Knapp et al (2011) in Knapp et al Mental Health Promotion…, Dept of Health.
Medically unexplained symptoms: the
economic case
Target
Individuals with sub-threshold somatisation and clinical
somatisation disorders in primary care (account for c.
25% of all primary care consulters)
Intervention
Referral to 10 sessions of cognitive behavioural therapy
over 6-month period; cost = £400
Outcome
evidence
CBT shown effective in reviews; 35% of individuals
report improvement in symptoms after 15-month
follow-up (Allen et al 2006)
Economic
pay-offs
Reduced NHS costs (GP consultations, prescriptions,
A&E, outpatients, inpatients); reduced sickness
absence from work
Findings
Total savings over 3 years = £1.75 per £1 invested for
comprehensive programme; savings = £7.82 per £1
invested for targeted programme. Majority of savings
accrue to NHS
McDaid et al (2011) in Knapp et al Mental Health Promotion…, Dept of Health.
Early detection of psychosis: the
economic case
Target
Young people aged 15-35 in general population with
prodromal symptoms of psychosis. Estimated number
per year = 15,763.
Intervention
Early detection service (based on OASIS in South
London; Valmaggia et al 2009). Consists of
psychological and pharmacological treatment.
Outcome
evidence
Reduced rate of transition to full psychosis and
reduced duration of untreated psychosis for those who
do develop it.
Economic Reduction in inpatient costs and lost employment,
pay-offs
reduction in homicide rate, reduction in suicide rate.
Findings
In short-term (Year 1) there is a net cost, but the total
return on £1 investment over a 10-year period is
£10.27 – 26% of this is to the NHS
McCrone et al (2011) in Knapp et al Mental Health Promotion…, Dept of Health.
Economic pay-offs per £1
investment
NHS
Other
public
sector
Nonpublic
sector
Total
Early identification and intervention as soon as mental disorder arises
Early intervention for conduct disorder
1.08
1.78
5.03
7.89
Health visitor interventions to reduce postnatal
depression
0.40
-
0.40
0.80
Early intervention for depression in diabetes
0.19
0
0.14
0.33
Early intervention for medically unexplained symptoms
1.01
0
0.74
1.75
Early diagnosis and treatment of depression at work
0.51
-
4.52
5.03
Early detection of psychosis
2.62
0.79
6.85
10.27
Early intervention in psychosis
9.68
0.27
8.02
17.97
Screening for alcohol misuse
2.24
0.93
8.57
11.75
Suicide training courses provided to all GPs
0.08
0.05
43.86
43.99
Suicide prevention through bridge safety barriers
1.75
1.31
51.39
54.45
9.42
17.02
57.29
83.73
School-based interventions to reduce bullying
0
0
14.35
14.35
Workplace health promotion programmes
-
-
9.69
9.69
Promotion of mental health and prevention of mental disorder
Prevention of conduct disorder through social and
emotional learning programmes
Addressing social determinants and consequences of mental disorder
Debt advice services
0.34
0.58
2.63
3.55
Befriending for older adults
0.44
-
-
0.44
Costeffectiveness
Cost-effectiveness
If the core clinical/care question is:
‘Does this intervention work?’
Then the economic question is:
‘Is it worth it?’
Which outcome dimensions?














Symptoms of illness
Extent of disability
Needs (met, unmet)
Social functioning
Self-care abilities
Employment, occupation, activities
Behavioural characteristics
Quality of life
Normalised lifestyle
Autonomy, choice, control
Family well-being
Carer ‘impact’
Societal perceptions (e.g. safety)
QALYs (quality-adjusted life years)
Characteristics of
a good outcome
measure:
 Relevant!
 Reliable
 Valid
 Sensitive to
change
 Succinct
 Acceptable to
patient
Possible CEA results
New treatment
less effective
and more
costly
E2 < E1
C2 > C 1
C
E
1
2
=
=
=
=
costs
effects
old treatment
new treatment
New
treatment
How
are the
more effective
outcomes
tradedbut also more
off against the
costly
costs?
New treatment
less effective
but less costly
E2 > E1
New treatment
more effective
and also less
costly
C2 < C 1
Trade-offs … is it worth it?
If an intervention is more effective and also more costly, then
calculate the cost per unit gain in effectiveness. Crunch
question: Is it worth it?
So we could:

Attach a monetary value to the outcome gain

Show decision-maker the cost-effectiveness of various
ways to spend their money and get them to choose

Show decision-maker the probability of costeffectiveness at different WTP values

… or ask them how much they are willing to pay?

Set a threshold, rigidly or as a guide (cf. NICE) …

… But then need a way to compare across different
diagnostic groups) … and hence use of QALYs, DALYs
Cost-effectiveness acceptability curve
(CEAC)
1.0
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
€10k
€20k
€30k
Value of threshold ratio
€40k
Example
Computerised Cognitive Behavioural
Therapy (CBT) for anxiety and
depression
Design n=274 primary care patients (aged
18-75) with depression and/or anxiety
disorder; not currently receiving face-toface psychological therapy. RCT
Interventions ‘Beating the Blues’ (BtB) – 8
sessions (50 mins each) of therapy on top
of usual care vs. treatment as usual
(TAU) alone (discussions with GP, referral
to counsellor, practice nurse or MH
professional, etc)
Aim To compare effectiveness and costeffectiveness of BtB and TAU
Proudfoot et al, Brit J Psychiatry 2004; McCrone et al, Brit J Psychiatry, 2004
Beating the Blues: results
Effectiveness
 BtB better than treatment as usual on clinical
measures of symptoms (Beck Depression Inventory,
Beck Anxiety Inventory) and functioning (Work and
Social Adjustment Schedule)
Cost
 BtB more costly than standard care (to NHS)
So is it worth it?
 Cost per 1 incremental gain on Beck Depression
Inventory = £21
 Cost per additional depression-free day = £2.50
 Cost per additional QALY = £2190
Proudfoot et al, Brit J Psychiatry 2004; McCrone et al, Brit J Psychiatry, 2004
Incentives
Using economic incentives
Providing information about what people do and the
associated economic consequences
Rewarding/penalising decision-makers for ‘good/bad
decisions’ or good/bad performance
Hence:
o
Fee for service … the GP contract
o
Payment by results (HRGs)
o
Incentive-based contracts / salaries
o
Provider competition within health / social care
o
Financial rewards for patients (e.g. FIAT)
Thank you
[email protected]
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