Objectives: We examined the impact of household income on the use of medical services in Japan, where there is a “health care for all” policy, with important, centralized influence by the national government designed to ensure universal access.

Methods and Subjects: All healthcare societies operating in 2003 were included in the study, representing 14,776,193 insured adults and 15,496,752 insured dependents. The mean case rate (the average number of monthly bills per patient), the mean number of service days per person, and the mean medical cost per person served as indicators of medical service use. Multiple regression analysis was performed by the forced entry method using case rate, the number of service days, and medical cost as outcome variables, and average monthly salary, dependent ratio, average age, and premium rate as the explanatory variables.

Results: In the multiple regression analyses, average monthly salary showed a high positive correlation of outpatient and dental indicators, including case rate, the number of service days, and medical cost. If the average monthly salary were reduced 20 percent lower than the mean, the estimated changes (95 percent CI) in case rate for the insured were −7.49 (−8.14 ∼ −6.84) percent for outpatient visits and −8.16 (−8.77 ∼ −7.56) percent for dental services.

Conclusions: Average monthly salary intensifies the effects of copayments on the case rate, the number of service days, and medical cost in the “Employees Health Insurance” in Japan. Thus, a low salary appears to discourage patients from seeking medical and dental services.

Objectives: The purpose of this study was to empirically explore whether individuals take their expected income into consideration when directly valuing predefined health states. This was intended to help determine how to handle productivity costs due to morbidity in a cost-effectiveness analysis.

Methods: Two hundred students each valued four hypothetical health states by using time trade-off (TTO) and a visual analogue scale (VAS). The students were randomly assigned to two groups. One group was simply asked, without mentioning income, to value the different health states (the non-income group). The other group was explicitly asked to consider their expected income in relation to the health states in their valuations (the income group).

Results: For health states that are usually assumed to have a large effect on income, the valuations made by the income group seemed to be lower than the valuations made by the non-income group. Among the students in the non-income group, 96 percent stated that they had not thought about their expected income when they valued the health states. In the income group, 40 percent believed that their expected income had affected their valuations of the health states.

Conclusion: The results show that, as long as income is not mentioned, most individuals do not seem to consider their expected income when they value health states. This indicates that productivity costs due to morbidity are not captured within individuals' health state valuations. These findings, therefore, suggest that productivity costs due to morbidity should be included as a cost in cost-effectiveness analyses.

The article “Key principles for the improved conduct of health technology assessments for resource allocation decisions” presents fifteen principles for health technology assessment. Many of these cannot be disputed, and application of the principles as stated would undoubtedly improve HTA as it is developing in the world at large. My question is, are these the most important principles? The document does not really try to answer this question.

In the first paragraph in the “Description of Studies” subsection and the sole paragraph of the “Procedure Time” subsection of the “RESULTS” section on page 257 of Volume 23 Number 2 of International Journal of Technology Assessment in Health Care, two tables are listed as “published on the Web site.” However, no link was provided.

Objectives: In the Netherlands, allocation decisions have not yet been explicitly based on the Value of Statistical Life. However, when policy makers decide whether or not to implement life saving interventions this trade-off is made implicitly. This study aimed to gain insights into this trade-off, hereafter referred to as Implicit Value of Statistical Life (IVSL), by means of a retrospective investment analysis of life saving interventions implemented in the Netherlands.

Methods: A literature search was conducted to find life saving intervention cases meeting the requirements for IVSL calculation. A final sample of ten cases was included in the study concerning interventions implemented in different societal sectors. For each case, an IVSL estimate was calculated according to a uniform method.

Results: IVSL estimates derived from the intervention cases differed considerably and ranged from €1 to almost €11 million. Differences were most extreme when comparing IVSL estimates concerning interventions implemented in different societal sectors. However, IVSL estimates also varied greatly between interventions in the same sector and even within the same interventions when critical assumptions were altered.

Conclusion: Our findings suggest that there are great imbalances between societal investments for preventing a statistical death. This highlights the need for further deliberation about how to improve transparency of policy decisions. An approach ex ante determining the Value of Statistical Life by means of empirical methods and based on societal preferences might circumvent the problems associated with the IVSL and needs further exploration.

The paper presents a set of principles that cover the broad scope of HTA from formulation of the question to effects on the decision-making process. It also provides goals for HTA programs to aim for in producing assessments. The principles are supported by material that includes illustrations from the experience of several programs. The authors have had long contact with the field and are well able to authoritatively discuss a range of methodological and other topics. The paper includes a range of views and details that are relevant to those involved with HTA.

“Key principles for the improved conduct of health technology assessment for resource allocation decisions.” The title says it all. I am amazed that such a summary is even possible and that it defines this field so well. Perhaps this report will be cited for years to come as the best and central definition of HTA. A field like this can be defined in other ways.

Objectives: The aim of this study was to benchmark the proposal forms used by a sample of Italian hospitals to inform the budget process for the adoption of new technology to understand the relationship with the guidelines provided by the Health Technology Assessment (HTA) literature.

Methods: A literature review was first undertaken to identify the frameworks developed to support decision making regarding new technology at a hospital level. A checklist of criteria drawn up according to five main perspectives (technology, patient, organization, economics, and level of evidence) has been formalized to review and compare the collected proposal forms.

Results: The “technology” perspective appears to have been broadly covered. The “patient” perspective has focused to clinical issues and partially neglects other dimensions such as patient satisfaction and potential adverse events. The “organization” dimension has paid little attention to change management. The “economics” dimension has been broadly covered, even though a sensitivity analysis has not been considered. The “level of evidence” that is required for submitting the proposal form is little.

Conclusions: The proposal forms used to inform the budget process regarding the adoption of new technology are accountable for a limited set of dimensions from among those proposed in literature. Further research is required to understand how to render technology assessment multidimensional, multidisciplinary, evidence-based, and accountable at a hospital level.

Our goal in formulating the proposed principles was to stimulate discussion of HTA program goals and procedures to enhance the rigor, validity, and usefulness of HTA. The thoughtful and constructive comments by David Banta, David Hailey, and Duncan Neuhauser are an excellent beginning to what we hope will be an extended and interactive process. We appreciate the opportunity to respond to some of their comments, suggestions, and critiques.

As more countries use HTA to inform decisions on the reimbursement of health technologies, harmonization of evidence requirements between jurisdictions has been proposed, mainly on the grounds of improved efficiency. Harmonization has the potential to avoid duplication of effort for both manufacturers and HTA bodies involved in preparing and reviewing HTA submissions for innovative technologies. However, it also carries risks of loss of local control over decisions, the application of general data standards which are not universally accepted and slowing the rate of development of innovation in the analytical disciplines supporting HTA. This study reviews the issues associated with harmonization taking into account the perspectives of the multiple stakeholders. This study draws on experiences from recent initiatives intended to promote the harmonization of HTA and experience from related fields, particularly regulatory approval of new medical technologies.

In the article entitled “Rapid reviews versus full systematic reviews: An inventory of current methods and practice in health technology assessment,” by Watt et al. in volume 24 number 2 (Spring 2008) of International Journal of Technology Assessment in Health Care, the affiliation of Stephen Blamey is incorrectly listed as Department of Health & Ageing. Dr. Blamey is the current Chair of the Medical Services Advisory Committee (MSAC). MSAC is an independent scientific committee comprising individuals with expertise in clinical medicine, health economics, and consumer matters. The Department of Health & Ageing administers funding and operations for MSAC. However, members of MSAC act independently of the Department. As Chair of MSAC, Dr. Blamey can be contacted through the Department. Dr. Blamey is not affiliated with the Department of Health and Ageing and his contribution to the above-mentioned article does not reflect its policy. Dr. Blamey wishes to apologize for this misunderstanding.

Objectives: To report on a workshop, and subsequent discussions, that reviewed the achievements and progress of the EuroScan collaboration since its establishment in 1999 to share information on the methods and results of early identification and assessment of new and emerging health technologies; considered challenges to the collaboration; and discussed its possible future direction.

Methods: A workshop was held in Stockholm in September 2006, with thirty-two participants from ten countries and representatives from EuroScan member agencies, policy makers involved in policy or decision making relating to new technologies, and invited external commentators from international HTA networks. The workshop used a mix of presentations, panel and audience discussions, and small group work to consider the achievements and challenges put forward.

Results: EuroScan has developed as a sustainable network, and has made progress on all tasks in its initial action plan, with the EuroScan information sharing database on new and emerging technologies being one of the collaboration's key achievements. Identified immediate concerns for the network included consideration of the impact of its current name and membership model; acknowledgement and publication of the full range of benefits of membership; contribution to and development of the database to encourage increased information sharing; and EuroScan's ongoing interaction with the wider HTA world.

Conclusions: The workshop was a useful mechanism for reviewing the work of EuroScan and for creating a platform to take the collaboration forward. The workshop affirmed the benefits of the network to individual members; posed some significant challenges to the network to consider; and acted as a stimulus for an interim name change to better represent the global membership, and a major review of the EuroScan database of identified and assessed emerging health technologies.