Highlights
- •No internationally accepted gold standard for unit cost calculation exists. Different analytical methods have been applied in the United Kingdom, The Netherlands, and Germany as part of their national unit cost programs.
- •Our study is the first to systematically investigate the impact of differing calculation methods on unit cost estimates.
- •The study drew on Austrian data for calculating the unit cost of general practitioner consultations. Based on 6 different methodological approaches, large variations (+173%) in unit cost estimates were observed.
- •More reflection on data sources and unit costing methodology should be devoted in health economic evaluations to achieve more valid and comparable cost estimates.
- •Future research should support the development of internationally and inter-sectorally harmonized unit costing methods.
Abstract
Objectives
To inform allocation decisions in any healthcare system, robust cost data are indispensable. Nevertheless, recommendations on the most appropriate valuation approaches vary or are nonexistent, and no internationally accepted gold standard exists. This costing analysis exercise aims to assess the impact and implications of different calculation methods and sources based on the unit cost of general practitioner (GP) consultations in Austria.
Methods
Six costing methods for unit cost calculation were explored, following 3 Austrian methodological approaches (AT-1, AT-2, AT-3) and 3 approaches applied in 3 other European countries (Germany, The Netherlands, United Kingdom). Drawing on Austrian data, mean unit costs per GP consultation were calculated in euros for 2015.
Results
Mean unit costs ranged from €15.6 to €42.6 based on the German top-down costing approach (DE) and the Austrian Physicians’ Chamber’s price recommendations (AT-3), respectively. The mean unit cost was estimated at €18.9 based on Austrian economic evaluations (AT-1) and €17.9 based on health insurance payment tariffs (AT-2). The Dutch top-down (NL) and the UK bottom-up approaches (UK) yielded higher estimates (NL: €25.3, UK: €29.8). Overall variation reached 173%.
Conclusions
Our study is the first to systematically investigate the impact of differing calculation methods on unit cost estimates. It shows large variations with potential impact on the conclusions in an economic evaluation. Although different methodological choices may be justified by the adopted study perspective, different costing approaches introduce variation in cross-study/cross-country cost estimates, leading to decreased confidence in data quality in economic evaluations.
Keywords
Introduction
To inform allocation decisions in healthcare systems, reliable and valid cost data based on methodologically sound unit cost information are indispensable. Unit costs are commonly defined as the value of all resources required to produce a service, divided by the level of activity the service generates.
1
International research shows that depending on the methodological approaches, huge variations between unit cost estimates for healthcare services may arise.Bonin E-M, Beecham J. Preventonomics Unit Cost Calculator v1.5 Guidance Document. Personal Social Service Research Unit, London. https://www.pssru.ac.uk/project-pages/unit-costs/pucc/. Accessed June 8, 2017.
2
, 3
, 4
, 5
Ultimately, this variation may affect the conclusions drawn from the economic evaluation. Yet existing guidelines provide little specific detail on appropriate costing sources and unit cost calculation methods.6
Generally, it is accepted that depending on the specific service and its role in the economic evaluation, different costing methods and sources may be appropriate.7
,8
From an economic perspective, unit costs should ideally capture the sacrifice made or the benefit forgone when a resource is consumed and hence not any more available for its best alternative use, that is, the opportunity cost,
8
,9
also referred to as the economic cost.10
In a perfectly competitive, free market, this cost is reflected in the market price. The healthcare system, however, features few of the characteristics of a free market and is prone to market failure. Consequently, government interventions are considered necessary, for example, through price regulation.To make costing data for healthcare-related services more standardized and readily accessible, several countries have introduced national unit cost libraries, including the United Kindgom,
11
, New Economy
Unit cost database.
Unit cost database.
http://neweconomymanchester.com/stories/832-unit_cost_database
Date accessed: January 19, 2017
12
, - Curtis L.
- Burns A.
Unit costs of health and social care 2015. Personal Social Services Research Unit.
https://www.pssru.ac.uk/project-pages/unit-costs/unit-costs-2015/
Date accessed: June 7, 2017
13
The NetherlandsUK Department of Health
NHS reference costs collection.
NHS reference costs collection.
https://www.gov.uk/government/collections/nhs-reference-costs
Date accessed: January 19, 2017
14
, 15
, 16
, 17
and Germany.18
, 19
, 20
The calculation of the listed unit costs follows a systematic methodology and is usually accompanied by a transparent description. In Austria, alternative sources for valuation including fees (tariffs/charges), tariff catalogs, and other administrative prices are recommended by the current pharmacoeconomic guideline (2006).Universität Hamburg: Netzwerk “Methoden der Messung der Inanspruchnahme von Gesundheitsleistungen und Kosten im Alter”: Modul B: Erstellung einer Datenbank für “unit costs” von Gesundheitsleistungen.
https://www.uke.de/institute/medizin-soziologie/downloads/institut-medizin-soziologie/methoden_gesund_kosten_alter.pdf
Date accessed: January 19, 2017
21
Such data may capture the costs from the analytical perspective of the payer, that is, the expenses made to fund such service provision. These expenses, however, do not necessarily equal the economic costs that arise in the service provision, because fees might be based on political negotiations rather than actual cost estimates. The methodological handbook for Austrian Health Technology Assessment (2012) points out that some experts therefore find market prices based on services funded by private insurances a more appropriate cost source instead.- Walter E.
- Zehetmayr S.
Economic evaluation guidelines. Institut für Pharmaökonomische Forschung Vienna.
https://tools.ispor.org/PEguidelines/source/Guidelines_%C3%96sterreich.pdf
Date accessed: August 3, 2017
22
If appropriate unit costs are not readily available from existing sources, they can be calculated based on top-down or bottom-up approaches.
23
In top-down costing, aggregate expenditures are assigned to individual services based on a defined metric. In bottom-up approaches, total costs are derived based on person-level service use information combined with costs.24
In its most precise form, that is, micro-costing, each component of resource use associated with the production of a service is estimated, valued, summed up, and then divided by the given unit of analysis (eg, per contact, per patient) to derive the unit cost.For Austria, a first unit cost library was set up by the Department of Health Economics (Center for Public Health) at the Medical University of Vienna in 2016 and has been regularly updated since.
25
The Department of Health Economics Unit Cost Online Database is a publicly accessible compilation of unit costs (currently 2004-2019) retrieved from Austrian costing studies and economic evaluations identified in a systematic review of the peer-reviewed and gray literature.Department of Health Economics (DHE), Center for Public Health, Medical University of Vienna: DHE Unit Cost Online Database: Cost Collection from Existing Studies.
http://healtheconomics.meduniwien.ac.at/science-research/dhe-unit-cost-online-database/
Date accessed: June 6, 2017
6
Although the database is a very limited step toward the systematic publication of cost data, an average of around 70 external downloads yearly and a total of 250 downloads (as of October 2019) emphasize the need for and interest in the collection of (standardized) unit costs at national level.In Austrian health economic analyses, unit costs are commonly taken from various administrative sources. Little reflection is typically given to the costing approach and unit cost sources,
26
similarly to other European countries where standardized unit cost catalogs are not available.27
Nevertheless, the impacts of the different sources and costing approaches on the unit cost estimates have not been comprehensively investigated so far.This article intends to determine whether different methodological approaches for unit cost calculation and publicly available unit cost sources are valid substitutes for each other, drawing on the example of general practitioner (GP) consultations in Austria. This example was chosen to reflect the frequency of information need as determined by the number of different unit cost estimates listed in the DHE Unit Cost Online Database. Overall, in Austria, 1 of 5 health economic analyses (n = 14, 19%) were found to rely on 1 or more GP visit-related unit costs.
25
Department of Health Economics (DHE), Center for Public Health, Medical University of Vienna: DHE Unit Cost Online Database: Cost Collection from Existing Studies.
http://healtheconomics.meduniwien.ac.at/science-research/dhe-unit-cost-online-database/
Date accessed: June 6, 2017
This article, therefore, addresses 2 research objectives. Firstly, the costing analysis exercise aims to increase awareness of relevant methodological issues to be considered in upcoming health economic studies and intends to inform future methodological discussions about different unit costing methods. Secondly, it aims to determine the unit cost of a single-practice GP consultation in Austria based on different Austrian and other European costing approaches to support future empirical economic evaluations and national decision making.
Methods
Institutional Background
In Austria, 99% of the population is covered by the mandatory health insurance system. Affiliation with one (or more) health insurance funds is determined by the individual’s residence or type of profession. Until recently, 19 insurance funds were in place, that is, 9 regional health insurance funds, 4 occupational health insurance funds, and 6 company health insurance funds. At the time of writing this article, a healthcare reform is ongoing, combining the regional health insurance funds as well as the company insurance funds into one fund and merging the occupational funds into another one. This reform will be effective from 2020 onward.
Ambulatory care in freestanding physician practices is provided by contracted and non-contracted GPs and specialists, who are self-employed and mostly operate in single practices. Contracted physicians are in a contractual relationship with 1 or more health insurance funds, whereas this does not apply to non-contracted physicians.
28
,29
Reimbursement of contracted GPs is based on tariff catalogs, which at the time of writing were negotiated between the health insurance funds and the 9 regional chambers of physicians, respectively, and approved by the Main Association of the Austrian Social Security Institutions. Tariff catalogs of the different health insurance funds seem mostly comparable regarding the included and reimbursed core services; however, they differ regarding the tariff value for comparable tariff positions and the extent of patient copayments.Contracted and non-contracted physicians can be consulted by any insured person. For non-contracted physician consultations, however, a maximum of 80% of the official health insurance fund tariff may be claimed by the patient for reimbursement. Around 36.5% of Austrians have complementary private health insurance, which may potentially cover these expenses.
30
Non-contracted physicians may determine their prices freely, but the regional physicians’ chambers provide price recommendations for some services. Although these recommendations are nonbinding, they are also used in case of legal disagreements between physicians and patients to judge the appropriateness of the charged price.31
- Tirol Ärztekammer
Practice-based physicians: non-contracted physicians.
http://www.aektirol.at/wahlarzte
Date accessed: January 19, 2017
Unit Costing Approaches
To determine the potential variations owing to methodological differences in a unit cost, 6 methodological approaches (AT-1, AT-2, AT-3, DE, NL, UK) were explored in this costing analysis exercise of a GP consultation in Austria. All estimates are based on Austrian data. All calculations were further validated by the team of authors following consultation with the data provider where necessary. Calculations based on the 3 approaches applied in 3 other European countries (DE, NL, UK) were informed by the descriptions and explanations provided in the given unit cost libraries, methods handbooks, and electronic online tools.
1
,Bonin E-M, Beecham J. Preventonomics Unit Cost Calculator v1.5 Guidance Document. Personal Social Service Research Unit, London. https://www.pssru.ac.uk/project-pages/unit-costs/pucc/. Accessed June 8, 2017.
32
Cost data including tariffs were obtained for the year 2015, or inflated to 2015 where necessary using the medical component of the consumer price index.Personal Social Services Research Unit
Preventonomics Unit Cost Calculator (PUCC).
Preventonomics Unit Cost Calculator (PUCC).
https://www.pssru.ac.uk/project-pages/unit-costs/pucc/
Date accessed: August 3, 2018
33
Microsoft Excel was used for all calculations.Statistics Austria
Health expenditure in Austria according to “System of Health Accounts”.
Health expenditure in Austria according to “System of Health Accounts”.
http://www.statistik.at/web_en/statistics/PeopleSociety/health/health_expenditure/index.html
Date accessed: January 19, 2017
Method AT-1 investigates the non–disease-specific GP unit cost information reported in published Austrian health economic evaluations. Relevant data were retrieved from the DHE Unit Cost Online Database
25
(version 2.1) and in line with earlier studies,Department of Health Economics (DHE), Center for Public Health, Medical University of Vienna: DHE Unit Cost Online Database: Cost Collection from Existing Studies.
http://healtheconomics.meduniwien.ac.at/science-research/dhe-unit-cost-online-database/
Date accessed: June 6, 2017
34
,35
a mean unit cost was calculated.Method AT-2 resembles the basic approach of the Austrian Main Association of Social Security Institution’s internal meta tariff system (Metahonorarordnung).
22
The meta tariff system is a nonpublic database implemented in 1995. It is organized as unified service catalog and includes around 1600 service positions,22
but generally does not include tariffs. It is based on the service positions included in the tariff catalogs of the 9 regional health insurance funds as well as the (nationwide valid) tariff catalogues of the 3 larger occupational health insurance funds.To develop a costing approach similar to the setup of the meta tariff system and calculate an average GP tariff across health insurance funds, a variety of assumptions had to be made. This was necessary since the different tariff catalogs are not fully comparable in their structure, included services, definitions, reimbursement schemes, and periods.
37
A weighted mean reflecting insured people across the 9 regional health insurance funds was calculated. This approach covers tariffs relevant for more than 3 quarters of the entitled Austrian population; however, it excludes 3 other health insurance funds that are covered in the official meta tariff system. This may result in an underestimation, because these 3 health insurance funds are considered to pay higher tariffs in general. At the same time, their reimbursement schemes cover 1 month rather than 1 quarter as for the regional health insurance funds, which would impede the overall comparability. Beside the publicly available information, relevant health insurance funds were contacted and asked for clarification where necessary.- Wilbacher I.
- Schröder J.
Combination of differen documentation systems.
http://www.hauptverband.at/cdscontent/load?contentid=10008.564464&version=1391184564
Date accessed: June 7, 2017
Method AT-3 is based on the (nonbinding) price recommendations by the regional physicians’ chambers for non-contracted physicians. A non-weighted mean of recommended GP consultation prices was calculated using available information published by 6 regional physicians’ chambers.
Method DE follows the German top-down approach of GP unit cost calculation,
18
,38
adjusted for system differences between Germany and Austria. The sum of all reimbursed GP tariffs for year 2015 as published in the Austrian physicians’ cost statistics (Ärztekostenstatistik) was divided by the total annual number of registered GP consultations to calculate the average cost per consultation.Method NL is in line with the Dutch bottom-up calculation method for standard costs.
14
,39
The mean annual reimbursement per GP based on tariffs (physicians’ costs statistics, 2015) was used in a first step. This number was then divided by the average annual working time taken from a GP survey conducted in 2011 to 201240
and an additional source,41
and adjusted for GP-reported patient-related time (81%)40
to calculate the hourly cost of a direct patient contact. Based on an estimate of 9.1 minutes as average consultation time,40
a mean unit cost per consultation was derived.Method UK is based on the UK micro-costing–like bottom-up approach.
12
Firstly, average GP income (before tax) including additional revenues and running costs was calculated. Specifically, income before tax derived from the average GP remuneration from health insurance funds and additional revenues (+18%, based on an estimate by the Ministry of Finance and the Main Association of Social Security Institutions)- Curtis L.
- Burns A.
Unit costs of health and social care 2015. Personal Social Services Research Unit.
https://www.pssru.ac.uk/project-pages/unit-costs/unit-costs-2015/
Date accessed: June 7, 2017
42
were added. Running costs were calculated as a share of income before tax plus additional revenues (63.0% in 2015), based on assumptions made in earlier studies.42
In line with the Dutch approach, this sum was divided by the average annual working hours and adjusted by the percentage of direct, patient-related time.40
The unit cost of a consultation was calculated based on the average patient contact duration.40
Results
Table 1 provides an overview of the calculated (mean) GP unit costs (year 2015) based on the 3 Austrian methodological approaches and the 3 methodological approaches applied in 3 other European countries using Austrian data. The different unit cost estimates range between €15.6 and €42.6, amounting to a variation of 173%.
Table 1Unit cost of a GP visit in Austria based on 3 Austrian methodological approaches and 3 approaches applied in 3 other European countries (2015).
| Method | Input estimates (in euro for year 2015) and their sources | Unit cost (in euro for year 2015) |
|---|---|---|
|
| 18.9 |
|
| 17.9 |
|
| 42.6 |
|
| 15.6 |
|
| 25.3 |
| 29.8 |
Note. Source: Own compilation. All values are presented for 2015 and were adjusted for inflation using the medical component of the consumer price index where necessary.
33
Statistics Austria
Health expenditure in Austria according to “System of Health Accounts”.
Health expenditure in Austria according to “System of Health Accounts”.
http://www.statistik.at/web_en/statistics/PeopleSociety/health/health_expenditure/index.html
Date accessed: January 19, 2017
GP indicates general practitioner.
Austrian Methodological Approaches
A total of 16 GP consultation–related unit costs were identified in the DHE Unit Cost Online Database (method AT-1). Of these, 7 unit costs referred to non–disease-specific consultations in a physician practice and were assessed further. In one case, the specific source of the unit cost was unclear, while in another case, it was merely described as expert advice. In 2 studies, the tariff catalog of the Viennese health insurance fund was used as unit cost source. In 3 studies, information was taken from the Main Association of Social Security Institutions. The mean unit cost per (first) consultation was estimated at €18.9 with reported unit costs ranging between €11.7 and €27.7.
Based on data retrieved from the health insurance fund tariff catalogs for the first patient contact and relevant calculations yielding estimates between €9.8 and €28.7, the mean unit cost of a GP consultation in Austria was calculated at €17.9 (method AT-2).
The recommended prices for non-contracted GP consultations amounted to €42.6 on average (minimum: €35.2, maximum: €50.4) (method AT-3).
Methodological Approaches Applied in 3 Other European Countries
Adopting the German costing methodology (method DE), the estimated unit cost per GP consultation was €15.6. Following the Dutch methodology (method NL), the average cost per GP consultation was estimated at €25.3. Based on the UK bottom-up micro-costing approach (method UK), the average unit cost was €29.8. This estimate could be reproduced with the UK Preventonomics Unit Cost Calculator.
Discussion
This is the first study comparing 6 different unit costing methodological approaches within the same context to investigate relevant variations and impacts on the resulting unit cost estimates using the average cost of a GP consultation in Austria as case study. Beside the undoubted national importance of the empirical results, the study also serves as a first methodological case example internationally. Large variations between the estimates driven by conceptual and methodological differences were identified. It is therefore not surprising if the limited acceptance and uptake of health economic evidence by policy makers is often driven by lack of confidence in data quality or robustness of the underlying value concepts.
43
,44
From a theoretical viewpoint, several aspects determine the appropriateness of different costing methodologies, including the purpose of the costing analysis exercise, the type and complexity of the health service, and requirements of generalizability and representativeness.
7
Furthermore, the adopted analytical viewpoint (eg, provider, third-party payer, patient, or societal perspective) defines which cost components are to be potentially included in an analysis (eg, healthcare costs, out-of-pocket expenses, costs arising in other sectors).8
In addition, the analytical viewpoint determines which sources are appropriate to value the resource use.2
,8
,26
This point is very clearly illustrated by the different methodological approaches explored in this case study. The unit costs listed in the DHE Unit Cost Online Database (method AT-1) were all used in economic evaluations conducted from the public payer or the societal perspective. In 1 case, GP unit costs were retrieved from the Main Association of the Social Security Institution, thus reflecting costs from the payers’ viewpoint but not necessarily economic costs in the opportunity cost sense.
45
Although a tariff might not bill all relevant costs for the service, it may capture the most relevant information from the payer perspective.Sensor Marktforschung
Attitudes towards the current primary health vcare system: group discussion with medical students.
Attitudes towards the current primary health vcare system: group discussion with medical students.
http://www.hauptverband.at/cdscontent/load?contentid=10008.603049&version=1414058399
Date accessed: June 7, 2017
7
,8
At the same time, since tariffs are eventually funded through the population’s social insurance contributions, it may be justified to accept them as proxies for actual costs also from the societal perspective.These considerations generally also apply to the estimate based on method AT-2, which was set up to adapt the Austrian meta tariff system. Note, though, that services funded by some occupational health insurance funds (eg, Civil Servants Insurance corporation) come with patient copayments (eg, 10% of the tariff). In economic evaluations from the societal perspective, this out-of-pocket cost would have to be considered on top of the reimbursed tariff to fully reflect societal costs, which in empirical studies seems rarely the case.
6
Several other methodological challenges are associated with method AT-2, specifically related to the complexity of the Austrian outpatient tariff catalogs. For example, many tariff catalogs include quantitative reimbursement limitations, and some services are reimbursed on a diminishing scale. The average tariff a GP eventually gets paid by a health insurance fund may therefore be different from the tariff listed in the catalog.
22
In practice, some GP consultations may also result in additionally reimbursed fee-for-service positions billed for extra services,46
which could not be considered in this costing analysis exercise. Estimates by Jung (2016) based on the 9 regional health insurance funds show that on average, 70% of GP revenues can be attributed to case fees and around 30% to individual services.46
Several limitations thus pertain to this unit cost estimate. This also shows in the unit costs previously reported in Austrian economic evaluations (method AT-1). Study authors often applied case fees per quarter and not reimbursements per consultation to value a single consultation.47
Therefore, these unit costs are a poor proxy for the cost of a second consultation, and their application in an economic evaluation would lead to an overestimation of GP costs.Generally, tariffs in the Austrian outpatient sector are seen as a result of political negotiations.
48
New services were added to tariff catalogs based on economic cost calculations only in the last few years.Rechnungshof: Funding and costs of services in hospital outpatient departments and physician practices.
https://images.derstandard.at/2012/06/12/Bund_2011_03_6.pdf
Date accessed: June 7, 2017
48
Differences in tariffs for the initial consultation and follow-up consultation are part of an incentive system to avoid initial under provision or supplier-induced follow-up demand, and may be considered tools to allow reimbursement differentiated by patient needs.Rechnungshof: Funding and costs of services in hospital outpatient departments and physician practices.
https://images.derstandard.at/2012/06/12/Bund_2011_03_6.pdf
Date accessed: June 7, 2017
46
Overall, however, the application of tariffs as unit costs remains questionable, for example, when it comes to appropriate reflection of the physicians’ different skill levels or time needed for the consultation.8
To date, however, there is no standardized documentation of diagnoses and therefore no effective regimen exists for quality assurance. It is thus difficult to assess the appropriateness of services and develop a quality-assurance driven tariff system.The recommended prices for non-contracted GP consultations (method AT-3) capture the privately insured payer viewpoint (ie, the patient and/or private health insurance perspective). Given that the market for private (non-contracted) GPs can be assumed to be fairly competitive,
29
it may be reasonable to assume that the price approximates the opportunity cost of the service.8
It also reflects the societal cost in case the patient submits the invoice for reimbursement to their complementary private health insurance fund. Nevertheless, the services of non-contracted GPs may not be directly comparable with those provided by contracted GPs. Average prices of non-contracted GP services, for example, are reported to start from €120 per hour.41
Non-contracted GPs generally treat lower number of patients but spend on average more time per consultation29
and may also incur higher expenses for additional training.41
Private prices are thus not directly comparable with the equivalent tariffs (method AT-2) and may be a biased proxy for public services.Method DE, following the German approach, takes on a public payer perspective and consequently a societal perspective
49
excluding patient copayments. The same applies to method NL. The general approach of method UK is closest to the opportunity cost concept as it reflects the costs from a physician’s perspective based on average labor and capital inputs. It also roughly follows the suggested approach of the Viennese Physicians’ Chamber for setting service prices for non-contracted physicians.41
,50
- Stepanek P.
Pricing for non-contracted physicians.
http://sobekb.aekwien.at/media/PreisgestaltungWahlaerztInnen.pdf
Date accessed: June 7, 2017
In a recent Delphi study among European health economists, it was agreed that opportunity costs would be the preferred valuation approach
9
with country-specific (nationally representative) standard costs being the recommended proxy measure. This recommendation is also in line with the societal perspective reflecting societal opportunity costs. Problems, however, arise when such unit costs are not available or when they are a closer reflection of costs from the healthcare perspective. This is also confirmed by this costing analysis exercise. For example, our case study highlights that among the unit costing approaches applied in 3 other European countries, the German and Dutch methods are closer proxies of the payer perspective. Nevertheless, one could argue that they also represent societal costs excluding out-of-pocket copayments where applicable. This shows that the adoption of one analytical perspective may indeed justify different unit costing approaches, thus introducing legitimate variation in unit cost estimates between different jurisdictions and studies.Methodological transparency and reflection, for example, based on more specific costing guidelines and detailed economic evaluation checklists regarding costing issues, may be a first step toward more sound unit cost estimates.
10
At the same time, owing to, for example, the practical differences between service providers and accounting arrangements, the need for some flexibility in costing guidelines and hence unit cost estimates will remain inevitable.1
,Bonin E-M, Beecham J. Preventonomics Unit Cost Calculator v1.5 Guidance Document. Personal Social Service Research Unit, London. https://www.pssru.ac.uk/project-pages/unit-costs/pucc/. Accessed June 8, 2017.
14
From a pragmatic standpoint, the appropriate time and effort to be invested in the costing of a service also depends on its (quantitative and qualitative) importance for an analysis.7
,8
,10
Although there is an inherent trade-off between resource intensity and precision, it is agreed that services most affected by an intervention should be valued based on more exact methods.10
Simpler valuation methods may be adopted for services that are, for example, less important for a given economic evaluation. Overall, these insights were also one of the driving motivations for PECUNIA, a large European project aiming to develop more standardized, harmonized, and validated multi-sectoral and multinational methods, tools, and information for costing in economic evaluations.51
Limitations
This costing analysis exercise needs to be interpreted in light of its potential limitations. Firstly, to address feasibility, transparency, and reproducibility, calculations aimed to be based on publicly available data retrieved from, for example, websites, legal documents, and scientific papers as far as possible. Although this was a deliberate choice, such approach has an inherent limitation of not always being able to draw on the most up-to-date information and in some instances reproduction may require individual data requests. This is, however, not uncommon in any unit cost calculation attempts nor limits the validity of the key messages of our article. Secondly, various assumptions had to be made for some calculation methods owing to differences in the tariff catalog lists of the health insurance funds. Merging some of the health insurance funds and harmonizing practice-based physician services is part of the ongoing Austrian healthcare reform. Hopefully in the future, therefore, relevant calculations will require less efforts in Austria in general.
Conclusion
Although unit costs based on tariffs may be an adequate valuation source from the payer’s perspective, also they are appropriate sources from the societal perspective, especially if relevant out-of-pocket costs are considered additionally. If available and for the more competitive parts of the healthcare market (but not for the public services), unit costs based on prices for private physicians seem to be a good proxy for opportunity costs.
Especially for important cost items included in a health economics analysis, more reflection on the data source and costing methodology is needed for unit cost calculations to achieve valid, comparable estimates that are also in line with the study’s overall costing perspective. Existing costing guidelines and quality checklists that fail to provide sufficient guidance should be updated. This will help to avoid unnecessary and unjustified variations between studies owing to differences in unit costing approaches. Nevertheless, for countries without available unit cost libraries such as Austria, a methodologically standardized primary costing study based on dedicated data collection seems imperative. This would substantially increase the quality of cost estimates in future health economic analyses and potentially improve the acceptability of such evidence in policy making.
Acknowledgment
This manuscript draws on fruitful discussions during the first International Unit Cost Workshop held in February 2016 at the Department of Health Economics at the Center of Public Health, Medical University of Vienna. We gratefully acknowledge the valuable inputs from all participants. Financial support by the Austrian Research Association (ÖFG) for this workshop was received. All views and opinions expressed in this article are those of the authors and do not necessarily reflect the views of the workshop participants, the PECUNIA consortium, or the funding agency.
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Article info
Publication history
Published online: July 27, 2020
Accepted:
June 16,
2020
Footnotes
Author Contributions: Concept and design: Mayer, Simon
Acquisition of data: Mayer, Zechmeister-Koss, Ostermann
Analysis and interpretation of data: Mayer, Fischer, Zechmeister-Koss, Ostermann, Simon
Drafting of the manuscript: Mayer, Simon
Critical revision of the paper for important intellectual content: Mayer, Fischer, Zechmeister-Koss, Ostermann, Simon
Statistical analysis: Mayer
Obtaining funding: Simon
Administrative, technical, or logistic support: Mayer, Fischer
Supervision: Mayer, Simon
Conflict of Interest Disclosures: The authors reported no disclosures.
Funding/Support: This study was conducted as part of the PECUNIA (ProgrammE in Costing, resource use measurement and outcome valuation for Use in multi-sectoral National and International health economic evaluAtions; grant agreement No 779292) research project funded by the European Union's Horizon 2020 research and innovation programme.
Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
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© 2020 ISPOR-The Professional Society for Health Economics and Outcomes Research. Published by Elsevier Inc.
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