Health technology assessment and healthcare environmental sustainability: Prioritizing effort and maximizing impact.

The growing global focus on and sense of urgency toward improving healthcare environmental sustainability and moving to low-carbon and resilient healthcare systems is increasingly mirrored in discussions of the role of health technology assessment (HTA). This Perspective considers how HTA can most effectively contribute to these goals and where other policy tools may be more effective in driving sustainability, especially given the highly limited pool of resources available to conduct environmental assessments within HTA. It suggests that HTA might most productively focus on assessing those technologies that have intrinsic characteristics which may cause specific environmental harms or vulnerabilities, while the generic environmental impacts of most other products may be better addressed through other policy and regulatory mechanisms.

Health Economics in a World of Uneconomic Growth.

Multiple, accelerating and interacting ecological crises are increasingly understood as constituting a major threat to human health and well-being. Unconstrained economic growth is strongly implicated in these growing crises, and it has been argued that this growth has now become "uneconomic growth", which is a situation where the size of the economy is still expanding, but this expansion is causing more harm than benefit. This article summarises the multiple pathways by which uneconomic growth can be expected to harm human health. It describes how health care systems-especially through overuse, low value and poor quality care-can themselves drive uneconomic growth. Health economists need to understand not only the consequences of environmental impacts on health care, but also the significance of uneconomic growth, and pay closer attention to the growing body of work by heterodox economists, especially in the fields of ecological and feminist economics. This will involve paying closer heed to the existence and consequences of diminishing marginal returns to health care consumption at high levels; the central importance of inequalities and injustice in health; and the need to remedy health economists' currently limited ability to deal effectively with low value care, overdiagnosis and overtreatment.

Pay-for-performance and patient safety in acute care: A systematic review.

Pay-for-performance (p4p) has been tried in all healthcare settings to address ongoing deficiencies in the quality and outcomes of care. The evidence for the effect of these policies has been inconclusive, especially in acute care. This systematic review focused on patient safety p4p in the hospital setting. Using the PRISMA guidelines, we searched five biomedical databases for quantitative studies using at least one outcome metric from database inception to March 2023, supplemented by reference tracking and internet searches. We identified 6,122 potential titles of which 53 were included: 39 original investigations, eight literature reviews and six grey literature reports. Only five system-wide p4p policies have been implemented, and the quality of evidence was low overall. Just over half of the studies (52 %) included failed to observe improvement in outcomes, with positive findings heavily skewed towards poor quality evaluations. The exception was the Fragility Hip Fracture Best Practice Tariff (BPT) in England, where sustained improvement was observed across various evaluations. All policies had a miniscule impact on total hospital revenue. Our findings underscore the importance of simple and transparent design, involvement of the clinical community, explicit links to other quality improvement initiatives, and gradual implementation of p4p initatives. We also propose a research agenda to lift the quality of evidence in this field.

How environmental impact is considered in economic evaluations of critical care: a scoping review.

PURPOSE: Health care is a major contributor to climate change, and critical care is one of the sector's highest carbon emitters. Health economic evaluations form an important component of critical care and may be useful in identifying economically efficient and environmentally sustainable strategies. The purpose of this scoping review was to synthesise available literature on whether and how environmental impact is considered in health economic evaluations of critical care. METHODS: A robust scoping review methodology was used to identify studies reporting on environmental impact in health economic evaluations of critical care. We searched six academic databases to locate health economic evaluations, costing studies and life cycle assessments of critical care from 1993 to present. RESULTS: Four studies met the review's inclusion criteria. Of the 278 health economic evaluations of critical care identified, none incorporated environmental impact into their assessments. Most included studies (n = 3/4) were life cycle assessments, and the remaining study was a prospective observational study. Life cycle assessments used a combination of process-based data collection and modelling to incorporate environmental impact into their economic assessments. CONCLUSIONS: Health economic evaluations of critical care have not yet incorporated environmental impact into their assessments, and few life cycle assessments exist that are specific to critical care therapies and treatments. Guidelines and standardisation regarding environmental data collection and reporting in health care are needed to support further research in the field. In the meantime, those planning health economic evaluations should include a process-based life cycle assessment to establish key environmental impacts specific to critical care.

The economic burden of myalgic encephalomyelitis/chronic fatigue syndrome in Australia.

Objective This study aimed to estimate costs of myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) to patients, government and Australian society. Methods Australian ME/CFS patients and their carers were recruited using convenience sampling. Patients completed an online retrospective cost diary, providing ME/CFS-related direct medical, non-medical and indirect costs. Informal care costs were collected directly from carers. Data from the Pharmaceutical Benefits Scheme and Medicare Benefits Schedule were linked to participant survey data. Annual per patient and total societal costs were estimated, broken down by category and presented in 2021 AUD. Factors associated with higher costs were investigated using generalised linear models. Results One hundred and seventy five patients (mean age 49 years s.d. 14, 79.4% female) completed the cost diary. Estimated total annual societal costs of ME/CFS in Australia ranged between $1.38 and $10.09 billion, with average annual total costs of $63 400/patient. Three-quarters of these costs were due to indirect costs ($46 731). Disability severity was the key factor associated with higher costs, particularly for indirect costs (being 2.27-fold higher for severe disability than no/mild disability). Conclusions ME/CFS poses a significant economic burden in Australia, owing mainly to high indirect and informal care costs.

How to measure progress towards a wellbeing economy: distinguishing genuine advances from 'window dressing'.

The world is experiencing multiple intersecting urgent and existential crises, which have profound and inequitable implications for population health. Arguably, the design of the current, dominant economic system and its antecedents is the root cause of these crises, as it externalises impacts on nature, climate and population health, exacerbates inequalities, and rewards extraction, rent-seeking and social hierarchy. A 'wellbeing economy', which aims to achieve social justice within planetary boundaries, has been proposed as an alternative approach to economic design. Many governments, businesses and organisations have expressed interest or commitment to this, but not at the required scale or with the required urgency. Indeed, there is the risk now that the radicalism of a wellbeing economy approach is undermined in its delivery thus far as it has either only been adopted in rhetoric or nascent form; or implemented only as isolated components rather than as part of a comprehensive shift. We, therefore, propose a series of criteria by which judgement can be made on whether progress towards a wellbeing economy is occurring: 1) Is the economy explicitly viewed by relevant actors as serving social, health, cultural, equity and nature outcomes, rather than the reverse?; 2) Is there a comprehensive and plausible pathway to design the economy in a way that achieves these outcomes?; 3) Is there a clear commitment to transitioning away from socially and ecologically damaging economic activities and doing so in a just way?; 4) Are there clear mechanisms that extend democracy over all sectors of the economy, including economic strategy and policy design, and in ownership of economic assets?; 5) Are negative externalities between policy areas or populations assessed and avoided, and positive externalities identified and promoted?; and 6) Are all the measures of economic success focused on social, health, cultural, equity and nature outcomes? We then apply these criteria using a series of examples to show contrasts between genuine wellbeing approaches and wellbeing economy 'window dressing'.

The economics of the wellbeing economy: Understanding heterodox economics for health-in-all-policies and co-benefits.

ISSUE ADDRESSED: The "wellbeing economy" represents a significant departure from the orthodox, neoclassical economic model of rational, utility-maximising individuals embedded in a growth economy. Emerging approaches to the wellbeing economy draw heavily upon insights from a range of heterodox schools of economic thought; these schools differ in many respects, but all share the central common insight that the economy is best conceived as a social provisioning system for humanity's needs. METHODS: This narrative review introduces and summarises key dimensions of a number of these heterodox economic approaches, all of which have had or are likely to have significant implications for wellbeing economics. Their relationship with wellbeing and their resulting approaches to public policy and the Health-in-All Policies (HiAP) approach is described and explored. RESULTS: The schools of heterodox economic thought which have had the most impact on the development of approaches to the "wellbeing economy" include ecological economics (including both post-growth and degrowth economics), feminist economics, and modern monetary theory. Recent developments in the economics of inequality and institutional economics have also been of significance. Yet HiAP approaches represent an attempt to incorporate consideration of health consequences within public policy processes inside the neoclassical economics paradigm, reflecting the reality that social and economic forces are typically the most important determinants of health. WHO's new Health For All approach draws much more directly on the heterodox economics that underpins wellbeing economy thinking. CONCLUSIONS: Wellbeing economics offers many attractive features for HiAP-but may not achieve its full potential within conventional economic policy paradigms. Calls to replace cost-benefit analysis with "co-benefit" analysis are attractive, but face strong practical obstacles. Meanwhile, strong countervailing forces and interests might still thwart achieving the broader goals of wellbeing economics. SO WHAT?: Operationalising "wellbeing economy" thinking requires a clear understanding of heterodox economics, and how they can be incorporated into more formal economic analysis. It remains to be seen if HiAP is the right tool by which to implement the new Health For All approach.

Challenges for Medicare and universal health care in Australia since 2000.

OBJECTIVES: To identify the financing and policy challenges for Medicare and universal health care in Australia, as well as opportunities for whole-of-system strengthening. STUDY DESIGN: Review of publications on Medicare, the Pharmaceutical Benefits Scheme, and the universal health care system in Australia published 1 January 2000 - 14 August 2021 that reported quantitative or qualitative research or data analyses, and of opinion articles, debates, commentaries, editorials, perspectives, and news reports on the Australian health care system published 1 January 2015 - 14 August 2021. Program-, intervention- or provider-specific articles, and publications regarding groups not fully covered by Medicare (eg, asylum seekers, prisoners) were excluded. DATA SOURCES: MEDLINE Complete, the Health Policy Reference Centre, and Global Health databases (all via EBSCO); the Analysis & Policy Observatory, the Australian Indigenous HealthInfoNet, the Australian Public Affairs Information Service, Google, Google Scholar, and the Organisation for Economic Co-operation and Development (OECD) websites. RESULTS: The problems covered by the 76 articles included in our review could be grouped under seven major themes: fragmentation of health care and lack of integrated health financing, access of Aboriginal and Torres Strait Islander people to health services and essential medications, reform proposals for the Pharmaceutical Benefits Scheme, the burden of out-of-pocket costs, inequity, public subsidies for private health insurance, and other challenges for the Australian universal health care system. CONCLUSIONS: A number of challenges threaten the sustainability and equity of the universal health care system in Australia. As the piecemeal reforms of the past twenty years have been inadequate for meeting these challenges, more effective, coordinated approaches are needed to improve and secure the universality of public health care in Australia.

Climate change, health and sustainable healthcare: The role of health economics.

Healthcare systems around the world are responding with increasing urgency to rapidly evolving ecological crises, most notably climate change. This Perspective considers how health economics and health economists can best contribute to protecting health and building sustainable healthcare systems in the face of these challenges.

Obesity and Bariatric Surgery in Australia: Future Projection of Supply and Demand, and Costs.

INTRODUCTION: The prevalence of obesity is increasing in developed countries, including Australia. There is evidence that bariatric surgery is effective in losing weight and reducing risk of chronic diseases. However, access to bariatric surgery remains limited in the public health sector. METHOD: We modelled population-based estimates of the likely numbers of people eligible for bariatric surgery in Australia using the recent Australian New Zealand Metabolic and Obesity Surgery Society (ANZMOSS) framework and estimated the potential costs that would be incurred from primary and subsequent reoperations in both public and private sector. RESULTS: The annual number of newly eligible patients is expected to rise, and hence the gap in demand is increasing relative to current baseline supply. If a 5-year program to treat all currently eligible patients was implemented, the maximum yearly demand is projected to be 341,343 primary surgeries, more than eight times the existing capacity of public and private sector, which can only offer 41,534 surgeries/year. A nine-fold increase is expected if we treat currently eligible patients over a 5-year program and all newly eligible patients as they occur each year. CONCLUSION: Our results highlighted the currently highly skewed distribution of bariatric surgeries between the private and public sectors. Improving access would bring substantial benefits to many Australians, given the demonstrated cost-effectiveness and cost savings. This requires a major increase in resourcing for publicly-funded access to bariatric surgery in the first instance. A national review of priorities and resourcing for all modes of obesity treatment is required in Australia.

Modelling the potential acute and post-acute burden of COVID-19 under the Australian border re-opening plan.

BACKGROUND: Concerns have grown that post-acute sequelae of COVID-19 may affect significant numbers of survivors. However, the analyses used to guide policy-making for Australia's national and state re-opening plans have not incorporated non-acute illness in their modelling. We, therefore, develop a model by which to estimate the potential acute and post-acute COVID-19 burden using disability-adjusted life years (DALYs) associated with the re-opening of Australian borders and the easing of other public health measures, with particular attention to longer-term, post-acute consequences and the potential impact of permanent functional impairment following COVID-19. METHODS: A model was developed based on the European Burden of Disease Network protocol guideline and consensus model to estimate the burden of COVID-19 using DALYs. Data inputs were based on publicly available sources. COVID-19 infection and different scenarios were drawn from the Doherty Institute's modelling report to estimate the likely DALY losses under the Australian national re-opening plan. Long COVID prevalence, post-intensive care syndrome (PICS) and potential permanent functional impairment incidences were drawn from the literature. DALYs were calculated for the following health states: the symptomatic phase, Long COVID, PICS and potential permanent functional impairment (e.g., diabetes, Parkinson's disease, dementia, anxiety disorders, ischemic stroke). Uncertainty and sensitivity analysis were performed to examine the robustness of the results. RESULTS: Mortality was responsible for 72-74% of the total base case COVID-19 burden. Long COVID and post-intensive care syndrome accounted for at least 19 and 3% of the total base case DALYs respectively. When included in the analysis, potential permanent impairment could contribute to 51-55% of total DALYs lost. CONCLUSIONS: The impact of Long COVID and potential long-term post-COVID disabilities could contribute substantially to the COVID-19 burden in Australia's post-vaccination setting. As vaccination coverage increases, the share of COVID-19 burden driven by longer-term morbidity rises relative to mortality. As Australia re-opens, better estimates of the COVID-19 burden can assist with decision-making on pandemic control measures and planning for the healthcare needs of COVID-19 survivors. Our estimates highlight the importance of valuing the morbidity of post-COVID-19 sequelae, above and beyond simple mortality and case statistics.

Impacts of chronic disease prevention programs implemented by private health insurers: a systematic review.

BACKGROUND: Chronic diseases contribute to a significant proportion (71%) of all deaths each year worldwide. Governments and other stakeholders worldwide have taken various actions to tackle the key risk factors contributing to the prevalence and impact of chronic diseases. Private health insurers (PHI) are one key stakeholders, particularly in Australian health system, and their engagement in chronic disease prevention is growing. Therefore, we investigated the impacts of chronic disease prevention interventions implemented by PHI both in Australia and internationally. METHOD: We searched multiple databases (Business Source Complete, CINAHL, Global Health, Health Business Elite, Medline, PsycINFO, and Scopus) and grey literature for studies/reports published in English until September 2020 using search terms on the impacts of chronic disease prevention interventions delivered by PHIs. Two reviewers assessed the risk of bias using a quality assessment tool developed by Effective Public Healthcare Panacea Project. After data extraction, the literature was synthesised thematically based on the types of the interventions reported across studies. The study protocol was registered in PROSPERO, CRD42020145644. RESULTS: Of 7789 records, 29 studies were eligible for inclusion. There were predominantly four types of interventions implemented by PHIs: Financial incentives, health coaching, wellness programs, and group medical appointments. Outcome measures across studies were varied, making it challenging to compare the difference between the effectiveness of different intervention types. Most studies reported that the impacts of interventions, such as increase in healthy eating, physical activity, and lower hospital admissions, last for a shorter term if the length of the intervention is shorter. INTERPRETATION: Although it is challenging to conclude which intervention type was the most effective, it appeared that, regardless of the intervention types, PHI interventions of longer duration (at least 2 years) were more beneficial and outcomes were more sustained than those PHI interventions that lasted for a shorter period. FUNDING: Primary source of funding was Geelong Medical and Hospital Benefits Association (GMHBA), an Australian private health insurer.

Scoping review: Development and assessment of evaluation frameworks of mobile health apps for recommendations to consumers.

OBJECTIVE: The study sought to review the different assessment items that have been used within existing health app evaluation frameworks aimed at individual, clinician, or organizational users, and to analyze the scoring and evaluation methods used in these frameworks. MATERIALS AND METHODS: We searched multiple bibliographic databases and conducted backward searches of reference lists, using search terms that were synonyms of "health apps," "evaluation," and "frameworks." The review covered publications from 2011 to April 2020. Studies on health app evaluation frameworks and studies that elaborated on the scaling and scoring mechanisms applied in such frameworks were included. RESULTS: Ten common domains were identified across general health app evaluation frameworks. A list of 430 assessment criteria was compiled across 97 identified studies. The most frequently used scaling mechanism was a 5-point Likert scale. Most studies have adopted summary statistics to generate the total scoring of each app, and the most popular approach taken was the calculation of mean or average scores. Other frameworks did not use any scaling or scoring mechanism and adopted criteria-based, pictorial, or descriptive approaches, or "threshold" filter. DISCUSSION: There is wide variance in the approaches to evaluating health apps within published frameworks, and this variance leads to ongoing uncertainty in how to evaluate health apps. CONCLUSIONS: A new evaluation framework is needed that can integrate the full range of evaluative criteria within one structure, and provide summative guidance on health app rating, to support individual app users, clinicians, and health organizations in choosing or recommending the best health app.

Toward a Sustainable Health System: The Changing Economic Paradigm.

Miller and Xie (2020) raise a call to action on creating a sustainable Canadian healthcare system as part of a more just and sustainable economic model. This commentary explores the economic dimensions of this call to action. It provides a brief overview of relevant concepts and insights from emerging schools of economic thinking, and contemplates challenges and opportunities for health system sustainability as the economic consequences of COVID-19 play out in coming years.

Health care, overconsumption and uneconomic growth: A conceptual framework.

Concerns have grown in recent decades that economic growth in many rich countries may, in fact, be uneconomic. Uneconomic growth occurs when expansion in economic activity causes environmental and social costs that are greater than the benefits of that additional activity. Health care has enjoyed a close historical relationship with economic growth, with health care spending consistently growing faster than GDP over the long term. This paper explores the possible relationship between health care and uneconomic growth. It summarises the rapidly growing evidence on the harms caused by poor quality health care and by the overuse of health care, and on the environmental harms caused by health care systems. Further, it develops a conceptual framework for considering the overconsumption of health care and the joint harms to human health and the natural environment that ensue. This framework illustrates how health-damaging overconsumption in the wider economy combines with unnecessary or low-quality health care to create a cycle of "failure demand" and defensive expenditure on health care services. Health care therefore provides important sectoral insights on the phenomenon of uneconomic growth. There are rich opportunities for interdisciplinary research to quantify the joint harms of overconsumption in health and health care, and to estimate the optimal scale of the health sector from novel perspectives that prioritise human and planetary health and well-being over GDP and profit.

Health care and the future of economic growth: exploring alternative perspectives.

The strong and positive relationship between gross domestic product (GDP) and health expenditure is one of the most extensively explored topics in health economics. Since the global financial crisis, a variety of theories attempting to explain the slow recovery of the global economy have predicted that future economic growth will be slower than in the past. Others have increasingly questioned whether GDP growth is desirable or sustainable in the long term as evidence grows of humanity's impact on the natural environment. This paper reviews recent data on trends in global GDP growth and health expenditure. It examines a range of theories and scenarios concerning future global GDP growth prospects. It then considers the potential implications for health care systems and health financing policy of these different scenarios. In all cases, a core question concerns whether growth in GDP and/or growth in health expenditure in fact increases human health and well-being. Health care systems in low growth or 'post-growth' futures will need to be much more tightly focused on reducing overtreatment and low value care, reducing environmental impact, and on improving technical and allocative efficiency. This will require much more concerted policy and regulatory action to reduce industry rent-seeking behaviours.