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5 Benefits of Learning Through the Case Study Method

• 28 Nov 2023

While several factors make HBS Online unique —including a global Community and real-world outcomes —active learning through the case study method rises to the top.

In a 2023 City Square Associates survey, 74 percent of HBS Online learners who also took a course from another provider said HBS Online’s case method and real-world examples were better by comparison.

Here’s a primer on the case method, five benefits you could gain, and how to experience it for yourself.

Access your free e-book today.

What Is the Harvard Business School Case Study Method?

The case study method , or case method , is a learning technique in which you’re presented with a real-world business challenge and asked how you’d solve it. After working through it yourself and with peers, you’re told how the scenario played out.

HBS pioneered the case method in 1922. Shortly before, in 1921, the first case was written.

“How do you go into an ambiguous situation and get to the bottom of it?” says HBS Professor Jan Rivkin, former senior associate dean and chair of HBS's master of business administration (MBA) program, in a video about the case method . “That skill—the skill of figuring out a course of inquiry to choose a course of action—that skill is as relevant today as it was in 1921.”

Originally developed for the in-person MBA classroom, HBS Online adapted the case method into an engaging, interactive online learning experience in 2014.

In HBS Online courses , you learn about each case from the business professional who experienced it. After reviewing their videos, you’re prompted to take their perspective and explain how you’d handle their situation.

You then get to read peers’ responses, “star” them, and comment to further the discussion. Afterward, you learn how the professional handled it and their key takeaways.

HBS Online’s adaptation of the case method incorporates the famed HBS “cold call,” in which you’re called on at random to make a decision without time to prepare.

“Learning came to life!” said Sheneka Balogun , chief administration officer and chief of staff at LeMoyne-Owen College, of her experience taking the Credential of Readiness (CORe) program . “The videos from the professors, the interactive cold calls where you were randomly selected to participate, and the case studies that enhanced and often captured the essence of objectives and learning goals were all embedded in each module. This made learning fun, engaging, and student-friendly.”

If you’re considering taking a course that leverages the case study method, here are five benefits you could experience.

5 Benefits of Learning Through Case Studies

1. take new perspectives.

The case method prompts you to consider a scenario from another person’s perspective. To work through the situation and come up with a solution, you must consider their circumstances, limitations, risk tolerance, stakeholders, resources, and potential consequences to assess how to respond.

Taking on new perspectives not only can help you navigate your own challenges but also others’. Putting yourself in someone else’s situation to understand their motivations and needs can go a long way when collaborating with stakeholders.

2. Hone Your Decision-Making Skills

Another skill you can build is the ability to make decisions effectively . The case study method forces you to use limited information to decide how to handle a problem—just like in the real world.

Throughout your career, you’ll need to make difficult decisions with incomplete or imperfect information—and sometimes, you won’t feel qualified to do so. Learning through the case method allows you to practice this skill in a low-stakes environment. When facing a real challenge, you’ll be better prepared to think quickly, collaborate with others, and present and defend your solution.

3. Become More Open-Minded

As you collaborate with peers on responses, it becomes clear that not everyone solves problems the same way. Exposing yourself to various approaches and perspectives can help you become a more open-minded professional.

When you’re part of a diverse group of learners from around the world, your experiences, cultures, and backgrounds contribute to a range of opinions on each case.

On the HBS Online course platform, you’re prompted to view and comment on others’ responses, and discussion is encouraged. This practice of considering others’ perspectives can make you more receptive in your career.

“You’d be surprised at how much you can learn from your peers,” said Ratnaditya Jonnalagadda , a software engineer who took CORe.

In addition to interacting with peers in the course platform, Jonnalagadda was part of the HBS Online Community , where he networked with other professionals and continued discussions sparked by course content.

“You get to understand your peers better, and students share examples of businesses implementing a concept from a module you just learned,” Jonnalagadda said. “It’s a very good way to cement the concepts in one's mind.”

4. Enhance Your Curiosity

One byproduct of taking on different perspectives is that it enables you to picture yourself in various roles, industries, and business functions.

“Each case offers an opportunity for students to see what resonates with them, what excites them, what bores them, which role they could imagine inhabiting in their careers,” says former HBS Dean Nitin Nohria in the Harvard Business Review . “Cases stimulate curiosity about the range of opportunities in the world and the many ways that students can make a difference as leaders.”

Through the case method, you can “try on” roles you may not have considered and feel more prepared to change or advance your career .

5. Build Your Self-Confidence

Finally, learning through the case study method can build your confidence. Each time you assume a business leader’s perspective, aim to solve a new challenge, and express and defend your opinions and decisions to peers, you prepare to do the same in your career.

According to a 2022 City Square Associates survey , 84 percent of HBS Online learners report feeling more confident making business decisions after taking a course.

“Self-confidence is difficult to teach or coach, but the case study method seems to instill it in people,” Nohria says in the Harvard Business Review . “There may well be other ways of learning these meta-skills, such as the repeated experience gained through practice or guidance from a gifted coach. However, under the direction of a masterful teacher, the case method can engage students and help them develop powerful meta-skills like no other form of teaching.”

How to Experience the Case Study Method

If the case method seems like a good fit for your learning style, experience it for yourself by taking an HBS Online course. Offerings span eight subject areas, including:

• Business essentials
• Leadership and management
• Entrepreneurship and innovation
• Digital transformation
• Finance and accounting
• Business in society

No matter which course or credential program you choose, you’ll examine case studies from real business professionals, work through their challenges alongside peers, and gain valuable insights to apply to your career.

Are you interested in discovering how HBS Online can help advance your career? Explore our course catalog and download our free guide —complete with interactive workbook sections—to determine if online learning is right for you and which course to take.

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Cost-effectiveness of Case Management: A Systematic Review

This systematic review found that studies of case management interventions have adequate quality and, in many cases, show cost-effective or even cost-saving results.

Objectives: In this time of aging and increasingly multimorbid populations, effective and efficient case management approaches play a crucial role in supporting patients who are navigating complex health care systems. Until now, no rigorous systematic review has synthesized studies about the cost-effectiveness of case management.

Study Design: A systematic review was performed.

Methods: The bibliographic databases PubMed and CINAHL Plus were systematically searched using key blocks and synonyms of the terms case management , effectiveness , and costs . The methodological quality of the studies was assessed using the Consensus Health Economic Criteria list.

Results: A total of 29 studies were included. In 3 studies, the intervention was less effective and more costly than the control group and can therefore be considered not cost-effective. Two studies found that the intervention was less effective and less costly. A more effective and less costly intervention, and therefore a strong recommendation for case management, was found in 6 studies. In 17 studies, the intervention was more effective while being more costly. Nearly half of the studies met most of the quality criteria, with 16 or more points out of 19.

Conclusions: Existing studies often have adequate quality and, in many cases, show cost-effective or even cost-saving results. Case management appears to be a promising method to support patients facing complex care situations. However, variation among case management approaches is very high, and the topic needs further study to determine the most cost-effective way of providing such care coordination.

Am J Manag Care. 2022;28(7):e271-e279. https://doi.org/10.37765/ajmc.2022.89186

Takeaway Points

• Case management approaches play a crucial role in supporting patients who are navigating complex health care systems.
• Case management intervention studies often have adequate quality and, in many cases, show cost-effective or even cost-saving results.
• Variation among case management approaches is very high, and the topic needs further study to determine the most cost-effective way of providing such care coordination.

Health systems around the world are getting more complex. This increasing complexity may affect patients’ ability to access the right health services at the right time. This struggle to navigate the system has individual implications for the care seeker’s well-being and economic implications when it results in wasting the health system’s scarce resources and delaying the provision of the right treatment to the right patient or providing unnecessary care. Case management programs intend to guide individuals with complex medical needs through the health system to improve health service effectiveness and the efficiency of service provision. The concept of case management is not new; it has been practiced in the United States for more than a century, primarily in the disciplines of nursing and social services. 1 Case management programs are generally designed to tackle the challenges of episodic care, which are often fraught with inadequate transitions between care services and health care settings. The programs aim to coordinate fragmented services by providing guidance to individuals, attempting to improve health service effectiveness and reduce cost. Ideally, a case management program facilitates communication and the coordination of care, and its collaborative practice includes patients, caregivers, nurses, social workers, physicians, payers, support staff, other practitioners, and the community. 2

The oldest and largest case management membership organization in the world, the Case Management Society of America, which facilitates the growth and development of case management, defines case management as “a collaborative process of assessment, planning, facilitation, care coordination, evaluation, and advocacy for options and services to meet an individual’s and family’s comprehensive health needs through communication and available resources to promote patient safety, quality of care, and cost-effective outcomes.” 3 As defined by the UK-based Medical Research Council as well, case management is quite complex. 4 The complexity of case management interventions arises from, among other factors, the number of groups or organizational levels targeted by the intervention, the number and variability of outcomes, the number and difficulty of behaviors required by those delivering or receiving the intervention, and the degree of flexibility or tailoring of the intervention. Furthermore, there is complexity in the intervention components, among them case finding and assessment, case planning, navigation and coordination, monitoring, and reviewing of the case plan. These components aim to improve continuity of care and to enhance patients’ self-management skills and hence are intended to increase efficiency within the health care system.

Especially in regard to the aging multimorbid population, case management may play an important role in the support of patients facing complex care situations. With better coordination, it is posited, the health system’s ability to provide high-quality care and maintain resource requirements can improve. One recent analysis of case management’s effectiveness is the RubiN project (funded by the Federal Joint Committee’s German Innovations Fund), which is evaluating the implementation of case management for geriatric patients. The goal of RubiN is to develop a form of care throughout Germany that enables older people to remain in their homes for as long as possible. It is hoped that by case managers informing and guiding patients and their (caretaking) relatives, the quality of treatment will rise—by closing gaps in care—and support will be provided to physicians—by conserving scarce personnel resources.

Here, we set out to provide an overview of the evidence regarding cost-effectiveness of case management; until now, no systematic review has been conducted on this topic. Yet systematic reviews that have been done on case management’s overall effectiveness are promising: They have found that case management can effectively reduce hospital use and improve satisfaction with care when chronic illnesses are present. 5-7 Furthermore, a systematic review of reviews has found evidence that case management interventions reduce health care utilization in patients with chronic illnesses. 8

However, the question of whether case management is cost- effective has so far not been adequately addressed. Further, it is unclear whether cost-effective case management interventions have certain characteristics in common. The aim of this systematic review is therefore to investigate the cost-effectiveness of case management.

Objectives and Study Design

The objective of this systematic review was to synthesize the evidence for cost-effectiveness of case management.We conducted a systematic review of the literature following the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. 9 Also, this review reported according to the PICOS (Population, Intervention, Comparison, Outcomes, Setting) Framework. 10 A protocol was developed before searching electronic databases.

Eligibility Criteria

Inclusion and exclusion criteria are outlined in Table 1 . Briefly, the review included cost-effectiveness studies that compare case management interventions with usual care. Model-based studies were excluded. No limits were applied to language and publication date.

Electronic Bibliographic Database Searches

The bibliographic databases PubMed and CINAHL Plus were systematically searched using key blocks of the terms case management , effectiveness , and costs and their synonyms. A complete search strategy list is provided in the eAppendix ( available at ajmc.com ).

Study Selection

Two authors (A.K.K. and J.J.) independently screened titles and abstracts from unduplicated references. The full text was reviewed when a decision was not possible from reading the abstract. Any discrepancies were resolved by discussion.

Data Collection and Synthesis

Data were collected using an extraction form developed to retrieve relevant information. This included study characteristics (nation, setting, patient group and sample size, comparison group, study design, type of economic evaluation, study duration), case management characteristics (case management model [with description], intensity of intervention, team or single case manager, training received, supervision, 24-hour availability of case manager, caseload per manager/team), and outcome characteristics (outcome measures, costs included, cost perspective, time horizon, cost analysis method, findings, sensitivity analysis/uncertainty assessment). The studies were summarized and synthesized by the first author independently. The extraction table is provided in the eAppendix.

Quality Assessment

The methodological quality of the cost-effectiveness analyses was assessed by the Consensus Health Economic Criteria (CHEC) list. 11 If a study qualified in a criterion, it scored 1; otherwise, it scored 0. Thus, this tool’s range was 0 to 19. In cases in which criteria were not applicable (eg, the question about the appropriate discount rate in a year-long study), the overall achievable score was reduced. Quality appraisal was verified by a second reviewer.

A total of 2388 unduplicated studies were retrieved from the database searches. After reading titles and abstracts, 61 full texts were analyzed, and inclusion and exclusion criteria were applied. From these, 32 studies were excluded. The remaining 29 studies were included in the qualitative analysis of the review. A flow diagram of this process, according to PRISMA guidelines, is presented in Figure 1 . 9

The results of the CHEC list show that nearly half of the studies (n = 13) met most of the quality criteria (≥ 16 of 19). 12-24 The main limitations were the narrow perspective chosen, as only about a quarter (n = 7) of all studies chose a broad societal perspective, 12,16,17,20,23,25,26 and the chosen short time horizon, which was only 1 year in about half the studies (n = 14). 13,16,19,26-36

Study Characteristics

Studies were from the United States (n = 12) 13-16,18,28,29,34,35,37-39 more than from any other nation, followed by studies from Germany (n = 8), 12,20,21,24,26,30,31,33 the Netherlands (n = 4), 17,19,22,23 the United Kingdom (n = 2), 32,40 Sweden (n = 1), 25 Denmark (n = 1), 36 and Canada (n = 1). 27 Except for one, 33 all studies were trial-based economic evaluations, assessing the cost-effectiveness of case management compared with usual care. Twenty-two of the economic evaluations were based on randomized controlled trials (RCTs) 12-16,18,20-30,32,34,36,39,40 ; the rest used non-RCT designs, such as nonrandomized controlled observational studies. Twenty of the studies adopted a health care system perspective in the analysis. 13-15,19,21,24,27-40 A societal perspective was adopted by 7 studies. 12,16,17,20,23,25,26 One study took the employers’ perspective. 18 One study adopted a health care perspective, a social care perspective, and a societal perspective. 22

Patient Groups

The patient group represented more than any other (see Table 2 12-40 ) were those with psychiatric disorders (n = 9), such as depressive disorders, anxiety, and/or posttraumatic stress disorder 12,15,16,18,22,30,31,35,39 ; they were followed by older patients (n = 4), 19,25,29,38 patients with dementia (n = 3), 17,24,33 and patients with diabetes (n = 2). 13,37 Further, several studies included patients belonging to more than 1 patient group, such as patients with diabetes and depression, 14 older patients with depression, 32,40 and older patients with myocardial infarction. 20,26 The rest of the studies included patients with HIV, 23 chronic obstructive pulmonary disease, 27,36 elevated blood pressure, 28 hypercholesterolemia, 34 and a long-term indication for oral anticoagulation therapy. 21

Case Management Model

In most studies, the case management interventions were described in enough detail to identify the program components. These components are case finding and assessment, case planning, navigation and coordination, monitoring, and reviewing of the case plan (Table 2 12-40 ).

The component of monitoring could be found in most descriptions of the case management intervention: Symptom monitoring and regular visits or telephone calls were described in 24 studies. Furthermore, the case management models often included navigation and coordination (n = 19) and health education (n = 17) components, such as informing the patient about the disease, counseling on general health behavior, emphasizing lifestyle changes, and promoting treatment adherence, self-care, and autonomy.

A combination of the components of monitoring and health education was often described, 13,15,21,23,27 as was the combination of monitoring and navigation/coordination. 14,32,37,39,40

A case management model with all components (assessment, case planning, navigation and coordination, monitoring, and health education) was described in 5 studies. 22,25,28,29,36

Case Managers

Case managers were nurses, health care assistants, social workers, physiotherapists, clinical therapists, pharmacists, and mental health workers. About half the studies (n = 14) stated that the case managers received training beforehand. The scope of the training received was heterogenous, with a duration of several hours, 2 days, or even 2 weeks. Case managers worked alone, although they frequently collaborated closely with the patient’s physician. Caseloads ranged between 10 and 76 patients, although 1 study analyzing a telecommunication-supported case management model stated a caseload of up to 120 less-active cases. 35

Outcomes and Costs

Highly heterogeneous among the studies were the outcomes. They included patient utility measures (eg, quality of life with EuroQol 5-dimension instrument, Short Form-36 questionnaire, World Health Organization Quality of Life), patient health effect measures (eg, mortality, symptoms, functioning in activities of daily living), other patient-relevant measures or system measures (eg, outpatient contacts, time in patients’ home environment, absenteeism), and situational program measures (eg, quality of parenting, abstinence).

Depending on the perspective chosen, intervention costs, direct medical costs (eg, inpatient and outpatient costs, emergency department costs, medication costs), direct nonmedical costs (costs for social support services [eg, community care such as nurse care and family support]), and indirect costs (eg, informal care costs and productivity losses) were included in the analyses of the studies. A table of perspectives chosen and costs included is provided in the eAppendix.

Economic Analyses

Findings regarding the economic analyses, the classification within the cost-effectiveness plane, and the results of the quality assessment using the CHEC list are listed in the results grid ( Table 3 [ part A and part B ] 12-40 ).

All except 2 studies 20,25 included an incremental analysis of costs and outcomes; most calculated an incremental cost-effectiveness ratio (n = 24) and conducted a sensitivity analysis (n = 24).

In Figure 2 , results are visualized in a cost-effectiveness plane, which is used to visually represent the differences in costs and health outcomes (effects) between treatment alternatives in 2 dimensions by plotting the costs against effects on a graph. Effects and costs are plotted on the x-axis and y-axis, respectively. The cost-effectiveness plane includes 4 quadrants: northwest (NW), southwest (SW), northeast (NE), and southeast (SE).

In 3 studies, the intervention was less effective and more costly than the control group (NW quadrant) and can therefore be considered not cost-effective. 19,30,35 The intervention is dominated by usual care.

Two studies found that the intervention was less effective and less costly (SW quadrant). One of these studies found that both costs (–€17.61) and effects (–0.0163 quality-adjusted life-years [QALYs]) were lower in the intervention group; therefore, the incremental cost-effectiveness ratio (€1080/QALY) represents the savings per additional QALY lost. 26 A study from the Netherlands, 17 which analyzed the cost-effectiveness of case management for patients with diagnosed dementia and their informal caregivers, found that the intervention saves costs and there is an approximately 45% chance that the intervention also has positive effects.

A more effective and less costly intervention (SE quadrant), and therefore evidence for cost-effectiveness, was provided in 6 studies. 12,20,24,27-29

The majority of studies (n = 18) found that the intervention was more effective while being more costly (NE quadrant). Of these, 7 studies reported incremental cost-effectiveness ratios below a willingness-to-pay threshold of US$50,000 for the gain of 1 QALY. 14,16,21,23,32,36,40 Only 1 study used QALYs and found that case management is not cost effective at US$50,000. 13 The remaining studies either used different outcome measures or did not provide a recommendation.

Case management interventions across all studies varied considerably. In cost-effective case management interventions, no patterns of common characteristics, such as case management model, type of case manager, or patient group, could be identified. No correlation of cost-effectiveness with a certain kind of health care system, study design, or time horizon could be observed either. Therefore, it remains unclear what makes some case management interventions cost-effective.

To our knowledge, this is the first systematic review that systematically synthesized studies to identify the cost-effectiveness of case management interventions. We identified 29 studies, which were published between 2000 and 2019. All studies compared case management to usual care without case management.

The results of the quality assessment of economic evaluations show that the quality of the included studies is good, although most studies chose a payer’s perspective and therefore did not include indirect costs such as productivity losses. In addition, in about half of all studies, the chosen time horizon was only 1 year. This is a short observation period, not appropriate to capture all relevant outcomes, because case management effects might be visible only after longer periods of time. In addition, considering that at the beginning of an intervention, costs of case management can be considerably higher because of up-front training costs, a relatively short study period of only 1 year might distort results. Results of the KORINNA studies illustrate this: After 1 year the case management for elderly patients with myocardial infarction was deemed less effective and less costly than usual care, 26 but a follow-up after 3 years 20 showed higher QALYs, significantly better quality of life, and lower costs (although not significantly lower). Hence, longer study durations are strongly recommended.

To provide successful case management, case managers require specialized training. However, only half of the studies stated that the case managers received training. A detailed description of the scope and content of training was scarce. The same applies for data on caseloads and descriptions of the intensity of case management—in other words, the patient contacts. We therefore recommend that studies provide detailed intervention protocols.

Limitations

The studies included conducted their interventions in 7 nations in which transferability of the data and conclusions to the German context was possible. Evidence from low- and middle-income countries was not included in this systematic review, and therefore its results may not be broadly applicable.

CONCLUSIONS

This systematic review found that because of a large variation in case management programs, the evidence for cost-effectiveness is not yet fully conclusive for case management in general. More definitive studies with a defined protocol of case management are needed to determine cost-effectiveness. However, the existing studies often have adequate quality and, in most cases, produce recommendable conclusions. The confluence of highly developed health systems, fragmented health care services, and aging populations with multimorbidity is a situation that calls out for individualized coordination and support. Case management appears to be a promising method to support patients facing complex care situations. We therefore advise policy makers to establish case management programs as core components of effective, patient-oriented health care systems, and to support rigorous evaluation of each program. 

Author Affiliations: inav – Institute for Applied Health Services Research (AKK, JJ, FF, MA), Berlin, Germany.

Source of Funding: This study was conducted in the context of the research project RubiN, funded by the Federal Joint Committee’s German Innovations Fund.

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (AKK, JJ, FF, MA); acquisition of data (AKK, JJ); analysis and interpretation of data (AKK, MA); drafting of the manuscript (AKK); critical revision of the manuscript for important intellectual content (JJ, FF, MA); administrative, technical, or logistic support (AKK, FF); and supervision (MA).

Address Correspondence to: Ann-Kathrin Klaehn, MSc, inav – Institute for Applied Health Services Research, Schiffbauerdamm 12, 10117 Berlin, Germany. Email: [email protected].

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advanced directives , decision making , ethics , palliative care

• Plakovic, Kathy MSN, APRN, ACHPN

Advanced directives allow patients to designate an agent to make decisions for them if they become incapacitated and unable to make their own decisions. Unfortunately, designating an agent does not ensure that that person understands the patient's preferences for treatment or has the ability to carry out the patient's wishes. This can leave end-of-life decision making up to individuals who may not be able to understand medically what is happening and may be too emotionally invested to make difficult decisions. Families may request nonbeneficial treatments in these situations that can raise ethical issues such as autonomy and nonmaleficence. Conflict within the family and between the family and health care team regarding the burdens and benefits of further treatment can lead to moral distress. The many dimensions that can influence health care decisions including communication about goals and values, the risks and benefits of proposed treatments, prognostication, and the family's and clinicians' response to the situation will be discussed. The palliative care advanced practice registered nurse can play a key role in providing information and supporting family during this difficult time. However, even with this support, family members may continue to have difficulty making end-of-life decisions for their loved ones.

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Burdens Versus Benefits

When family has to decide how much is too much.

Plakovic, Kathy MSN, APRN, ACHPN

Kathy Plakovic, MSN, APRN, ACHPN, is palliative care nurse practitioner, Edward Hospital, Naperville, Illinois.

Address correspondence to Kathy Plakovic, MSN, APRN, ACHPN, Edward Hospital, Palliative Care, 801 S Washington St, Naperville, IL 60540 ( [email protected] ).

Some details are changed to protect the confidentiality of the patient and family.

The author has no conflicts of interest to disclose.

Advanced directives allow patients to designate an agent to make decisions for them if they become incapacitated and unable to make their own decisions. Unfortunately, designating an agent does not ensure that that person understands the patient’s preferences for treatment or has the ability to carry out the patient’s wishes. This can leave end-of-life decision making up to individuals who may not be able to understand medically what is happening and may be too emotionally invested to make difficult decisions. Families may request nonbeneficial treatments in these situations that can raise ethical issues such as autonomy and nonmaleficence. Conflict within the family and between the family and health care team regarding the burdens and benefits of further treatment can lead to moral distress. The many dimensions that can influence health care decisions including communication about goals and values, the risks and benefits of proposed treatments, prognostication, and the family’s and clinicians’ response to the situation will be discussed. The palliative care advanced practice registered nurse can play a key role in providing information and supporting family during this difficult time. However, even with this support, family members may continue to have difficulty making end-of-life decisions for their loved ones.

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To be or not to be: legal and ethical considerations in suicide prevention.

Published online by Cambridge University Press:  02 January 2018

Making potentially critical clinical decisions in complex cases with the real risk of death by suicide is a most challenging job in psychiatry. Sadly, risk assessment and management of harm to self is a largely ignored area compared with risk of harm to others. The legal and ethical challenges are more nuanced, and contemporary training schemes and textbooks on psychiatry have not always done justice to this area, where front-line clinicians require probably most assistance. This article is an attempt to integrate the seemingly disparate threads from legal, ethical and clinical realms to assist decision-making, and it introduces a set of principles for managing these in clinical practice. It refers in particular to legislation in England and Wales, but the clinical and ethical issues discussed are universal.

‘There is but one truly philosophical problem and that is suicide. Judging whether life is or is not worth living amounts to answering the fundamental question of philosophy.’

Albert Camus ( The Myth of Sisyphus , 1942)

Psychiatrists in England have found themselves at the centre of government strategy following its proposed reduction of the suicide rate by one fifth by 2010 ( Department of Health 1999 ). However, Camus' words reflect the enormity of the challenge faced by doctors and nurses asked to assess a person who is thought to be suicidal. The act of suicide is no longer illegal in the UK (in light of the Suicide Act 1961), but aiding and abetting a suicide remains so. Although mental health legislation does not mandate clinicians to prevent a person putting themselves at risk, failure to prevent suicide in an identifiable victim may put hospital trusts and clinicians at risk of civil suits for negligence. Recent case law has found trusts liable for failure to prevent the suicide of patients known to pose a ‘real and immediate’ risk of taking their own lives ( Savage v South Essex Partnership NHS Foundation Trust 2008 ) and has considered the deaths of both formal and informal patients to be the result of negligence ( Rabone v Pennine Care NHS Foundation Trust 2012 ), ordering trusts to pay pecuniary damages to next of kin ( Reynolds v United Kingdom 2012 ). Heading a five-member judicial bench, Lord Walker in the Rabone case stated: ‘if there was a real and immediate risk of suicide at [the material] time of which the trust was aware or ought to have been aware, then in my view the trust was under a duty to take reasonable steps to protect [the patient] from it’. He defined real risk as ‘a substantial or significant risk and not a remote or fanciful one’ and immediate risk as ‘present and continuing’ ( Rabone v Pennine Care NHS Foundation Trust 2012 ).

Notably, there is major criticism of the way that risk was quantitatively calculated by the psychiatric experts in the Rabone case. The defence expert cited a risk ‘of the order of 70%’, whereas the trust expert accepted a ‘50% risk’ ( Rabone v Pennine Care Trust 2009 ). No rationale was provided as to how these risk probabilities were calculated, and Reference Large, Ryan and Callaghan Large et al (2012) suggest that they might be affected by hindsight bias.

It is notoriously difficult to gauge the risk of suicide in self-harming individuals or to decide what treatment should be provided, who should provide it and where. One of the best validated instruments, Beck's Suicide Intent Scale, has a positive predictive value (PPV) of only 4%, i.e. it successfully predicts only 4 out of 100 self-harming patients who will later die by suicide ( Reference Harriss and Hawton Harris 2005 ). Nevertheless, individual professionals are likely to be seen as negligent if a patient at high risk of suicide dies in their care. Perhaps a doctor does not detain the patient ‘at the right time’ or a nurse meant to be observing the patient leaves their post for a few minutes. They are now more than ever likely to be exposed to legal action in the wake of these case judgments. At the very least, they will face disciplinary and professional hearings by their respective regulatory bodies.

In this article, I discuss three aspects of clinical decision-making with regard to suicidal or self-harming patients. First, I set out the empirical challenges encountered by clinicians in assessing risk. Second, I explore the ethical questions that arise from cases involving suicide and self-harm: especially the balance between respect for patient autonomy and the exercise of healthy paternalism in a climate of risk-averse health policy. Finally, I offer a set of principles that busy clinicians can use to deal with common clinical, legal and ethical problems in practice. I do not claim that these are definitive or exhaustive: only that they are based on practical experience of managing cases of high-risk, repetitive self-harm by patients with extremely complex needs.

Clinical conundrums

Clinical conundrums come in the form of problems such as how to differentiate a patient who is suicidal from one who is self-harming but has no wish to die. As it is notoriously difficult to treat a behaviour, for that is what suicidal acts are, should one focus on clinical syndromes? But patients with clinical syndromes such as personality disorders are very difficult to manage as they alienate carers, and those with substance use disorders cannot be treated involuntarily under English mental health law. Should one instead focus on high-risk periods or methods of self-harm?

Whom to treat?

Although the risk factors for suicide are well established, predicting who will actually take their own life is not so easy. For example, patients with a history of self-harm are more than four times as likely to die by suicide than those without such a history. However, people who self-harm outnumber those who take their own life, i.e. although most people who die by suicide have self-harmed, only a subgroup of those who self-harm go on to kill themselves ( Reference Appleby, Shaw and Kapur Appleby 2006 ). As noted earlier, the use of psychometric risk measures adds little in these cases.

There is also a complication and expense in enforcing mental health legislation. Many who repeatedly self-harm are not seeking help or care; indeed, some actively refuse it or assault those who are trying to prevent them from self-harming ( Reference Sarkar Sarkar 2011a ). Reducing their risk of dying by suicide often requires detention under the Mental Health Act 1983, at a time when there are fewer beds for this purpose. Detention may also imply support under Section 117 of the Act, which includes assertive attempts at engaging patients (e.g. telephone calls, home visits or contact with the patient's family) ( National Confidential Inquiry into Suicide and Homicide by People with Mental Illness 2009 ). Following the Wooltorton case ( Box 1 ), capacitous patients may refuse medical treatment after self-poisoning and may also refuse to engage with psychological therapies recommended by clinicians. It seems clinically futile to detain someone under the Mental Health Act to prevent them from harming themselves if they are simultaneously refusing to be helped. However, the legal position is that if there is ‘real and immediate risk to life’ about which the authorities know or ought to know, they have a duty to do ‘all that reasonably could [be] expected’; failing to do so will lead to (legal) consequences that can be devastating, not just for the patient but also for the staff and the service ( Savage v South Essex Partnership NHS Foundation Trust 2008 ).

BOX 1 Capacitous refusal of life-saving treatment for self-harm

In 2007, Ms Kerrie Wooltorton was not prevented from dying by suicide by her local hospital. She was a 26-year-old woman with a history of depression and some evidence of disordered personality traits. In the previous 12 months, she had been admitted to mental health units on several occasions; and there were nine separate incidents where she had drunk industrial antifreeze. In September 2007, in accordance with the Mental Capacity Act 2005, Ms Wooltorton made an advance refusal of life-saving medical treatment in the event of her poisoning herself. She indicated that she was fully aware of the consequences of refusing such treatment. Three days after drafting the advance refusal, she made her final suicide act of drinking antifreeze. She called an ambulance, not from a desire to have life-saving treatment, but because she did not want to die in her flat alone.

At the subsequent Coroner's hearing, there was considerable controversy. On the one hand, a young woman was deemed to have capacity to make a decision that her life was no longer worth living, despite having recognised mental disorders and having had previous psychiatric treatment. Her history of mental disorder and treatment were not considered adequate reasons preventing her from making a capacitous decision to end her life. On the other hand, it was possible to see the mental health services as having abandoned their duty of care to a young person in a highly distressed and disordered state of mind. Note that her history and presentation contained several high-risk factors associated with completed suicide, which often lead to detention for treatment:

• she had a known, treatable mental disorder

• in the previous 12 months she had made several attempts to take her life

• she had received previous psychiatric treatment

• she gave advance notice of her intention to die through a potentially fatal method of self-harm.

Ms Wooltorton's parents threatened to sue for medical negligence, and the government of the day stated that ‘it was not the intention of the [mental capacity] law to give legal force to such suicidal advance decisions’ ( Reference Bingham Bingham 2009a ). Contrary to the case of Savage ( Savage v South Essex Partnership NHS Foundation Trust 2008 ) the Coroner's Court did not criticise the clinicians, but acknowledged that doctors who were aware of her history had judged Ms Wooltorton to be capacitous at the time of drafting the advance refusal. The coroner concluded that it would have been ‘unlawful’ for doctors to intervene in the wishes of a person with ‘full knowledge’ of what she was doing at the time she drafted her advance directive ( Reference Bingham Bingham 2009b ).

There is an interesting overlap here in terms of the ethical duties of doctors. Treating every individual who self-harms as though they are at potential risk of suicide will entail a significant increase in clinical resources. It may also result in so many false positives that true positives may be missed. In terms of best use of resources, it might be better to focus on high-risk individuals, and not only on anyone who cuts themselves ( Reference Runeson, Tidemalm and Dahlin Runeson 2010 ). However, such an approach means that some individuals will die by suicide because no algorithm is 100% accurate, and cases deemed to be low-risk will turn out to be occult ‘high-risk’.

What to treat?

Might it make more sense clinically to focus on high-risk factors such as diagnosis, not behaviours? This is true to an extent. The two most common single diagnoses among those who die by suicide are affective disorders (46%) and schizophrenia (19%); next, a large proportion (29%) have diagnoses of personality disorder, drug and alcohol misuse, anxiety or adjustment disorders ( Reference Appleby, Shaw and Kapur Appleby 2006 ). So even if clinicians targeted the two categories of serious mental illnesses that can be easily treated with pharmacotherapy, there would still be a sizeable group who would need more complex care packages; and (as already mentioned) might refuse to engage. Similarly, the sheer numbers would be a challenge for current resources. For example, if every person with a drug or alcohol problem is assessed for suicide risk, and offered treatment, this would mean offering therapy to thousands more people.

When to treat?

Does knowledge of high-risk periods help the clinician? A study by Reference Gunnell, Hawton and Ho Gunnell et al (2008) found that the risk of suicide in the month after psychiatric in-patient care was around 100 times greater than that for general population. More than 6.5% of all patients discharged from psychiatric in-patient care were readmitted for an episode of self-harm within 12 months, with a third of these episodes occurring in the 4 weeks after discharge, thereby sharing many of the features of suicide after discharge. The risk of self-harm in this period was higher in females, younger people, those with diagnoses of depression, personality disorder and substance misuse, and those with shorter lengths of stay. However, these data do not help clinicians to easily determine who should be allowed to go home with advice, who should be persuaded to stay voluntarily in hospital and who should be detained against their will. They also do not often tell the clinician who should receive the full force of psychiatric input in terms of monitoring and support.

In summary, assessing and acting on the risk of suicide presents many of the same clinical challenges as managing the risk of violence ( Reference Sarkar, Agrawal, Bolton and Gaind Sarkar 2011b ). There are a number of well-established actuarial risk factors (age, gender, diagnosis and past behaviour), but no accurate algorithm for establishing which of the people with these risk factors are actually at high risk of completing a suicidal act. Further, it is in the nature of suicide (as it is in fatal violence to others) that some deaths occur impulsively, in the absence of any known risk factors, or unintentionally. Hindsight bias may make such cases appear ‘obvious’ later, but this is a cognitive illusion ( Reference Kahneman Kahneman 2011 ).

Ethical considerations

Philosopher and ethicist Tom Beauchamp has argued that, in Western society, people are allowed to take risks with their lives if their decisions are made capacitously, which requires that they have ‘the ability to grasp, appreciate the significance of, form relevant intentions and not be controlled by either internal or external forces that [they] cannot resist’ ( Reference Beauchamp, Regan, Beauchamp and Callicott Beauchamp 1993 ). This capacitous autonomy over one's life is protected if a decision emerges out of rational logic, even though it results in one's death – the so-called ‘rational suicide’ ( Reference Brandt, Battin and Mayo Brandt 1980 ). Most modern societies consider this to be morally permissible as long as the decision is understandable or the individual's actions bring benefit to society (e.g. soldiers going to war, fire-fighters risking their lives or astronauts going into outer space). However, when a risky course of action by an individual is driven solely by personal wishes and desires that appear to lack logic or reason, or have little or no benefit to society, most modern societies do not unconditionally support the individual's personal autonomy and self-determination. For example, people who engage in extreme sports may not be able to take out life insurance: even though it is not their intention to kill themselves, society speaks through tacit discouragement of such behaviours.

But what of individuals who are under the legal age of consent, or who have intellectual disabilities or mental disorder? Are they permitted a ‘rational suicide’? No. Our society considers that the decision by such a person to take their own life is ‘irrational’ (as judged by clinicians and approved by law) and therefore morally impermissible ( Reference Brandt, Battin and Mayo Brandt 1980 ), for their lives are considered to be ‘worth living’ ( Reference Glover Glover 1990 ).

The notion of sanctity of life is championed by theologians of all hues, and most religions assert that life is a gift from the creator and taking it shows disrespect towards God ( Reference Baelz, Battin and Mayo Baelz 1980 ). It is likely that someone who is depressed forgets all that they usually get out of life. This is probably true regardless of the cause of the depression: long-term severe depressive disorder, a transient episode associated with a personality disorder, or a challenging life event such as bereavement, injury or unemployment. On the other hand, someone who fears death, possibly because of the belief that they would go to hell, may wish they had never been born, but still not want to die.

Who decides?

Clinicians are sometimes required to make judgements on life and death issues on behalf of their patients. The risks of allowing someone other than the person whose life it is to determine which lives are ‘worth living’ and ‘worth saving’ is a highly controversial matter ( Reference Glover Glover 1990 ). It may be difficult to separate one's own views from those of society about what constitutes a life worth living or a life worth saving. This moral decision is what often determines to which individuals a society will ‘cause death to save other lives’ ( Reference Glover Glover 1990 ), which individuals are ‘allowed’ to take their own lives, which ones are forced to endure lives of tremendous hardship and pain, and which individuals are taken care of by society irrespective of how intensely they wish to die. The eugenics programmes of several nations in the early 20th century and the excesses of Nazi Germany are not too distant reminders of the risks implicit in such a process.

Mental health law is a social response to the profound ethical dilemmas posed by adults who are a risk to themselves or others as a result of mental disorder or distress. The ethical tension is between respect for autonomy and liberty to be left alone and the public duty of society to protect those who are vulnerable. All mental health legislation is a trade-off between the principles of respect for autonomy and liberty on one side and the principle of respect for welfare on the other ( Reference Adshead and Sarkar Adshead 2005 ), and on occasion it leads to medical paternalism.

Medical paternalism

For a clinician to decide whether it is ‘appropriate’ to prevent someone from taking their own life is an example of medical paternalism. The Mental Health Act 1983, which governs England and Wales, allows for individuals with a recognised (in international classificatory systems) mental disorder to be detained for appropriate treatment if their illness is of a sufficient nature or degree to require hospital treatment. This ultimately boils down to an assessment as to whether the person, as a result of the mental disorder, poses a significant danger to themselves, their own health or to others. Amendments to the Act in 2007 require a demonstration by the detaining authority that ‘appropriate medical treatment’ exists to treat the condition that the potentially detained patient has. In terms of a suicidal patient, this requires the clinician to consider whether it is appropriate to detain the person simply to prevent suicide or whether appropriate treatment can ameliorate the condition to the extent that the person no longer remains at risk of suicide at the end of treatment. This determination allows that clinician to override the person's wishes, even if they retain mental capacity to make a reasoned decision.

There has been particular concern about the mental legislation of England and Wales because it is strongly paternalistic in that it allows for the detention and involuntary treatment of capacitous, and therefore autonomous, individuals because clinicians consider it is ‘appropriate’ to do so. The consequence of this is a coercive anomaly in that, if one has full mental capacity, one can refuse any medical treatment; but it is not possible to refuse admission to a psychiatric hospital or even physical/pharmacological treatment. An attempt to introduce a capacity-based mental health act (whereby one would have to show that a person lacked capacity before involuntary detention and/or treatment) ( Reference Richardson Richardson 1999 ) failed under the Labour government of 1999 and the current coalition government has done nothing to change the status quo . This suggests a political will to ensure that those considered to be mentally disordered are treated differently from the rest of the society when it comes to autonomy; a sad commentary on Liberal Democrat principles.

Autonomy and best interests

In psychiatry, respect for autonomy may mean that a clinician will allow a patient to make decisions free of coercion, even if this may appear to go against the patient's best interests – the basis of assessing capacity in statute law. Ethical principles for assessing capacity are now enshrined in law, in the Mental Capacity Act 2005 for England and Wales. They are as follows:

• people are assumed to have capacity to make their own decisions unless otherwise proven

• everything should be done to help a person arrive at a decision before declaring them incapable of making it

• whatever is done for a person lacking capacity should be done in their best interests

• the decision maker should choose the least restrictive intervention.

For instance, where someone is found in a state of semi-consciousness following a large overdose and their life is at stake, the Mental Capacity Act would require that immediate action be taken in the person's best interests to save life. It would not be practical or reasonable to go on an exhaustive fact-finding mission before initiating treatment. However, beyond the emergency phase, while a person still lacks capacity, the Act requires a much more concerted assessment of the person's capacity, the views of their carers or appointed attorneys, formal assessment of their best interests and consideration of any advance decisions. Within this Act, an advance decision is specifically a decision to refuse treatment made in advance and in writing. If it was prepared at a time when the patient had capacity, an advance decision is legally binding unless there are legitimate questions as to its validity or applicability (see the Wooltorton case outlined in Box 1 ). Further guidance is contained in the Code of Practice accompanying the Mental Capacity Act ( Department for Constitutional Affairs 2007 ).

Challenges in judging capacity

Doctors, by virtue of their professional training, have access to people at their most vulnerable; and duties that entail physical contact that may even cause harm or damage. For this reason, the law on consent is a dominant component of medical jurisprudence. No medical intervention can be imposed on an individual without consent; and to do so would amount to an assault. The legislation on consent reflects the respect of the law for individual autonomy and choice, as indicated in Collins v Wilcox [1984] : ‘The integrity of every person's body, save by consent, is established in law’.

This principle was made explicit in the case of Re T (Adult: Refusal of Treatment) [1992] , where it was specifically emphasised that, ‘ prima facie , every adult has the right and capacity to decide whether or not he will accept medical treatment, even if a refusal may risk permanent injury to his health or even premature death’.

It is now established that competent adults can refuse life-saving treatment. This is consistent with the repeal of the Suicide Act 1961, and in light of other legal decisions about the capacity to make unwise decisions. Debate still continues with regard to situations in which competent adults want to end their lives, but need assistance to do so. This debate is typically couched in terms of voluntary euthanasia or the ‘right to die’. In some jurisdictions, such as Oregon, USA, and The Netherlands, it is legally possible for competent adults to be assisted to die by licensed physicians.

Such debates are problematic for psychiatric services, where the wish to die is usually taken to be prima facie evidence of a disordered mind. Indeed, in both the USA and The Netherlands those who wish to end their lives are required to undergo a psychiatric assessment that excludes the possibility of the decision being a ‘symptom’ of any of the diagnoses known to be associated with a risk of suicide. As described earlier, a person who attempts suicide can be detained under the Mental Health Act if they have a mental disorder and if it is appropriate to detain them. The purpose of the detention is to prevent them from killing themselves, even if they possess the capacity to make the decision to do so.

The law currently implies that it is clinically straightforward to distinguish between a wish to die that is the result of a competently made decision that must be respected in law, and a wish to die that is a symptom of a treatable mental illness. In reality, it is not as simple.

Fluctuating capacity and the tripartite model

What is a clinician to do when a patient's capacity changes from day to day and week to week? Severe disturbances of affect and arousal regulation cause rapid oscillations in a person's perceptions about themselves, their world and their anticipated future ( Reference Sarkar and Adshead Sarkar 2006 ); and equally oscillating decisions about accepting or refusing life-saving care and treatment ( Reference Sarkar Sarkar 2008 ). These are states of mind in which there is fluctuating capacity, a phenomenon that has been largely ignored in capacity judgments to date ( Reference Sarkar and Beeley Sarkar 2011c ). Despite a slew of legislation that can bewilder clinicians, fluctuating capacity raises the problem that theoretical principles do not necessarily address real, complex clinical issues ( Reference Mogg and Bartlett Mogg 2005 ). The bar in assessing capacity must be set high when clinicians make best interests decisions when someone's life is at stake, as in the case of suicidal patients. This approach was recognised by the Court of Appeal in Re MB (An Adult: Medical Treatment) [1997] when it was stated that ‘the graver the consequences of the decision, the commensurately greater the level of competence required to make that decision’.

Case law on capacity suggests that temporary factors such as confusion, shock, fatigue, pain, drugs or panic can completely erode capacity ( Royal College of Psychiatrists 2004 ). Clinicians will add to this list other factors, such as dissociation and problems of self-identity, rapidly fluctuating mood and behaviours, and concomitant risk of harm to others ( Reference Gallagher and Sheldon Gallagher 2010 ; Reference Sarkar Sarkar 2011a ). This highlights the real clinical challenge of working out a person's real intent and choices and decisions when they are in great distress. I argue that it is imperative to consider a third element in capacity decisions ( Reference Sarkar Sarkar 2008 ). This is the determination of how ‘stable’ or ‘settled’ a decision judged to be capacitous actually is. If it is affected by or a product of underlying mental disorder, it may change with the illness over time. Therefore, a written decision cannot simply be accepted as the final and enduring decision of the individual. English capacity legislation requires that the person's past and present wishes and feelings – expressed verbally, in writing or through behaviour or habits – beliefs and values (e.g. religious, cultural, moral or political) that would be likely to influence the decision in question are taken into consideration when best interests judgements are made by others.

It is critical that clinicians take a longitudinal view of the capacity of all patients. In other words, just because a person appears to be capacitous at the time of assessment (a cross-sectional view) does not mean that they will be capacitous the next week, the next day or even the next hour. A useful strategy is to go beyond the current approach to capacity assessment based on the Mental Capacity Act, which is often limited to two specific elements: that the decision be informed and that it be clearly communicated to others.

Reference Eastman and Hope Eastman & Hope (1988) state that capacity decisions are not binary (present or absent) but graded, i.e. there are degrees of capacity. Different decisions about treatment that a patient is required to make would demand different levels of capacity. They suggest combining the complexity of the decision and the significance of outcome (based on the decision made) in what they call ‘the balance model’. However, this approach has been criticised as being potentially too paternalistic because it can have a tendency to focus too much on the desirability of outcome ( Reference Mogg and Bartlett Mogg 2005 ).

I propose an ‘enhanced’ approach to the balance model of capacity judgements if there are relatively rapid changes in the person's mental state, leading to rapid changes in capacity and risks. The ‘enhanced’ tripartite model requires three elements to be assessed: the rationale or logic behind the decision made; the conviction with which the decision is held and is aligned with the patient's life narrative, beliefs and values; and the clarity with which this decision is communicated to others ( Table 1 ). It is suggested that these three elements, when assessed together, are likely to address the confounding effect that fluctuating capacity has on issues of consent ( Reference Mogg and Bartlett Mogg 2005 ), which can often lead to reluctance of clinicians to treat in difficult cases ( Reference McCall Smith McCall Smith 2001 ). By trying to ensure that the decision is stable, enduring and consistent with the patient's frameworks of value and meaning, this approach provides the clinician with a strategy to limit paternalism as much as possible. The clinician's tasks therefore include:

• judging whether the decision (e.g. to self-harm, discharge from voluntary admission, go on leave from hospital) is informed and balanced

TABLE 1 A tripartite model of capacity judgement in relation to a wish to die

• judging whether it is communicated clearly and unambiguously

• judging the conviction with which it has been made by assessing its stability and endurance over time: the more important the decision and the more final its consequences, the longer the time frame should be over which its stability is assessed.

Conclusions

Managing self-harm and risk of suicide are complex tasks. Although recent case law directs the clinician's mind to assessing risk of suicide and acting according to it in a longitudinal way, current clinical practice often lags behind on account of categorisation of such risk. Risk of self-harm and suicide and, by extension, a patient's capacity to make rational choices are most often categorised as ‘present’ or ‘absent’. Clinical decisions that flow from such cross-sectional categorical determinations of risk are likely to be truncated judgements on a matter that needs to be judged in a more dynamic and longitudinal manner. The proposed tripartite model can be used to eliminate difficulties associated with fluctuating capacity in patients with complex needs and risks. In practice, it has been found to add a certain degree of rigour to clinical decision-making. Time will tell whether such an approach is widely adopted by clinicians.

Select the single best option for each question stem

1 The balance model of Eastman & Hope states that capacity:

a is a binary concept

b decisions are easy to make

c is either present or absent

d is graded into degrees

e need not be always assessed.

2 Fluctuating capacity refers to:

a capacity that is either present or absent

b decisions that are rapidly changing

c decisions made in an intoxicated state

d the approach recommended in the Mental Capacity Act 2005

e an issue routinely addressed by clinicians.

3 In the Rabone suicide case, the Court made a landmark judgment in terms of:

a making hospitals not liable for irresponsible acts of their patients

b making hospital authorities remove all ligature points in psychiatric wards

c making consultants legally responsible for deaths of their patients

d holding the carers of patients legally responsible for their deaths

e making hospitals legally responsible for preventing suicide where a ‘real and immediate’ risk has been identified.

4 Under the mental health legislation of England and Wales, people with terminal physical illness but no mental illness:

a are permitted to take their own life regardless of their mental capacity

b can get help from their carers to assist them in taking their own life

c can appeal to the European Court of Human Rights if they are prevented from taking their own life

d cannot be prevented from taking their own life if they are demonstrably capacitous in the opinion of consultant psychiatrists

e are not required to demonstrate capacity.

5 Suicidal individuals with mental illness who possess capacity:

a pose significant challenges in terms of society's duty to save their lives

b can be prevented under the Mental Capacity Act from taking their own life

c are always allowed to take their own lives, under mental health legislation of England and Wales

d should not be detained under the Mental Health Act

e are not encountered in practice.

MCQ answers

This is the last of four articles in this issue of Advances discussing suicide. See also pp. 276–283, 284–291, 292–294.

Declaration of Interest

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• Volume 19, Issue 4
• Jaydip Sarkar
• DOI: https://doi.org/10.1192/apt.bp.112.010595

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How much is too much? What does the US actually spend on health care administration?

Elsa pearson sites.

• April 4, 2018

Elsa Pearson is a Policy Analyst with Boston University’s School of Public Health. She tweets at @epearsonbusph .  Research for this piece was supported by the Laura and John Arnold Foundation.

The United States spends much more on health care each year than wealthy equals around the globe. That’s not just true for spending on direct patient care, but also for spending on health care administration. Many scholars recognize the cost containment potential in curbing administrative costs. Determining just how much the US spends on health care administration and in what ways are critical first steps.

How much of US health care spending is on administration?

Health care administration includes all activities related to coordinating health and medical services, such as scheduling, billing, and claims processing. Administrative costs’ contribution to overall health care spending is large and growing.

System-level estimates for health care administrative costs are limited and often dated. One highly cited estimate suggests that administrative costs accounted for about 30% of total health care expenditures in 1999. In 2006-2007 , administrative costs outpaced growth in other health care categories, such as professional services, and matched growth rates in typically costly categories, such as prescription drug spending.

Though we may not be able to pin down a current estimate of total administrative costs, we do know it’s substantial and continues to increase. Other research focuses on administrative costs in three, large subcategories: billing and insurance-related (BIR) costs, hospital administration, and physician practice administration.

BIR Administrative Costs

BIR costs are often an easily quantifiable subcategory of administrative costs. The National Academy of Medicine calculated the US spent about $361 billion on BIR costs alone in 2009, or 14.4% of total health expenditures . That number only seems to multiply; another study suggests the same costs totaled $471 billion in 2012, or 16.8% of total health expenditures (with 80% directly related to the US’ multi-payer system).

A case study of an academic health care system by Tseng, et al . showed that BIR costs accounted for 14.5% of professional revenue collected during primary care visits (as well as 25.2% during discharged ED visits and 13.4% during ambulatory surgical visits). The authors estimated the monetary impact of this administrative burden on primary care providers equated to almost $100,000/year/provider.

Hospital Administrative Costs

Research by Himmelstein, et al . found that US hospitals spend about 25% of total hospital expenditures on administration. For-profit hospitals tend to have the highest administrative costs. (This does not equate to better care, however, as for-profit hospitals often have higher death rates as well.)

Blanchfield, et al . conducted a case study of a large teaching hospital’s physician organization to determine the impact of administrative costs on the organization’s bottom line. While understood it was already a “high performance billing organization” and, thus, already ahead of the curve in reducing wasteful spending, the study found that excessive administrative costs accounted for about 12% of the organization’s revenue in 2006, or about $45 million. Processing and billing of claims alone accounted for 12.5% of those administrative costs, or $5.6 million.

Physician Practice Administrative Costs

Sakowski, et al . found administrative costs to consume 10% of revenue in a multispecialty medical group. In order to successfully maintain administrative procedures, the organization employed two administrative staff for every three clinical providers.

Research by Casalino, et al . concluded that medical practices spend about $68,000/year/physician interacting with health insurance plans. Primary care physicians, especially those in private practice, feel the most impact. Over three quarters of participants indicated that the costs associated with health plan interactions had increased within a two year period. Similarly, Papanicolas, et al . found that over half of surveyed physicians found insurance-related administrative tasks to be a significant burden.

Worth noting, high administrative costs are not just associated with misuse of resources but rather also accrue in efficient health care systems.   Tseng, et al . found no glaring inefficiencies in billing practice, such as task duplication or poor resource management, during their analysis. Blanchfield, et al . studied a physician organization with streamlined billing practices as well.

How does US health care administration spending compare to other countries?

When compared to 11 other wealthy countries, the US leads the pack in health care administration spending.

Himmelstein, et al .’s 2010-2011 estimate of about 25% of total hospital expenditures devoted to administration exceeds the Netherlands’, the next highest spender, by about 5.5 percentage points. US hospital administrative spending exceeds Canada’s and Scotland’s, the lowest spenders, by about 13 percentage points. In fact, US administrative costs have risen over the past decade while Canada’s costs have decreased.

Similar comparisons exist at the physician level as well. Morra, et al . compared the resources spent in 2006 on provider-payer interactions by small physician practices in both the US and Canada (specifically, Ontario). Canadian practices spent only 27% of the financial resources on provider-payer interaction that US practices did. Canadian support staff—nurses and administrative staff—spent one tenth of the time on these interactions compared to US support staff. The authors estimate the US could save $27.6 billion/year on administrative costs by adopting Canadian administrative practices.

Why are administrative costs so high in the US?

Though studies provide various hypotheses on why US health care administration is so expensive, the big picture is always the same: it’s structural.

The United States utilizes a largely private, multi-payer system . The complex payment scheme may cause systemic fragmentation , leading to additional, unnecessary administrative costs. Private insurers contribute the largest share of billing and insurance-related costs in the US ($198 billion in 2012 ) and, because the US health care system relies on them so heavily, their significant financial footprint may contribute to high overall administrative costs.

(A new Health Affairs article from Gottlieb, et al . explores billing complexity across insurance types—both public and private—in the US. They found, in general, that higher billing complexity led to higher administrative costs. The article provides fresh insight into US administrative costs and we will unpack the details in a future TIE post.)

The Netherlands, the nation with the second highest administrative expenditures, also has a multi-payer system , and one that is moving towards a market-based approach. Canada, on the other hand, has a single payer system and—coincidently?—has the lowest national hospital expenditures.

What should we do about high administrative costs in the US?

It’s worth acknowledging that administration costs are not automatically bad. Morra, et al . suggest “administrative tasks are wasteful [only] if their costs exceed the benefits they generate or if the same benefits could be achieve at a lower cost.” Policies to reduce administrative costs should aim to reduce waste while preserving worthwhile administrative activities.

A single payer health care system is often considered the “gold standard” for reducing administrative costs. However, most would agree that adopting a single payer system in the United States is a political nonstarter, though it certainly is gaining momentum in public opinion .

There are ways reap many of the administrative benefits of single-payer without moving to it. This would rely on standardization, simplification, and automation.

Standardization & Simplification

Every US payer operates within its own unique system—unique forms, processes, and rules. A “ single-payer approach ,” with one set of rules and operations for all payers, could reduce administrative costs. All individual payers would utilize the same claims forms, submission methods, etc., under a universal operating framework.

The current health care financial system is complex and often burdensome to providers and administrative staff and a simplified financial system may have significant cost-savings potential , or at the very least, reduce waste. Streamlining other administrative activities, such as credentialing, quality measurements, or benefit eligibility, could also contribute cost savings in the long-term.

Minimizing waste in the current system could lead to substantial savings. Berwick, et al . emphasize reducing administrative complexity (such as, inefficient rules and procedures) and reducing fraud/waste (both actual scams and the procedural regulations put in place because of them). The authors estimate that poor performance in these two categories accounted for $189-661 billion of wasteful spending in 2011.

Health information technology (HIT) and electronic health records (EHR) were developed, in part, with the intent of streamlining administrative tasks and patient care, resulting in long term cost savings.

Effectively conducting correspondence, payments, and insurance-related activities electronically may reduce administrative costs. Lee, et al . argue that the current rush towards EHR implementation lends itself as a natural opportunity for improvement. The Health Information Technology for Economic and Clinical Health Act (HITECH Act) was created to provide financial motivation for EHR implementation. A 2015 CDC report suggests the HITECH Act may have successfully incentivized providers to adopt some sort of EHR system.

Cutler, et al . propose the HITECH Act lays the foundation for comprehensive electronic correspondence. Expanding HITECH legislation to include electronic transmittance of other pertinent administrative data, such as claims data, may be a logical way to create system-wide reductions in administrative costs. The authors speculate an annual savings of $2 billion through this proposal.

However, the current use of HIT and EHR doesn’t seem to reduce administrative costs in the US as anticipated. Tseng, et al . conducted their analysis within a health care system with a complete EHR system and a centralized billing organization. The authors report administrative costs still had a significant financial impact even in light of these technological advances.

Reducing health care administration costs in the United States could have both direct and indirect impacts on the health care system as a whole. Most obvious would be the potential monetary savings by curtailing wasteful spending accrued through superfluous administrative activities. Providers could also see a positive impact on their relationships with patients, reclaiming the three hours/week spent on administrative duties for clinical care and increasing physician productivity.

US health care prices are the highest in the world. Some of that is due to ever growing administrative costs. So far, we haven’t found ways to keep those costs from rising. Overhauling the US health care system in its entirety seems unlikely. Some restructuring of health care administration could be a plausible first step towards reducing costs without harming patient care.

• Health Policy
• administrative costs , LJAF

Elsa Pearson Sites, MPH, is the policy director of the Partnered Evidence-based Policy Resource Center with Harvard T.H. Chan School of Public Health. She tweets at @epearsonbusph.

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Death by Information Overload

New research and novel techniques offer a lifeline to you and your organization.

Reprint: R0909J

The value of information in the knowledge economy is indisputable, but so is its capacity to overwhelm consumers of it. HBR contributing editor Hemp reports on practical ways for individuals and organizations to avoid getting too much of a good thing.

Ready access to useful information comes at a cost: As the volume increases, the line between the worthwhile and the distracting starts to blur. And ready access to you —via e-mail, social networking, and so on—exacerbates the situation: On average, Intel executives get 300 e-mails a day, and Microsoft workers need 24 minutes to return to work after each e-mail interruption. Clearly, productivity is taking a hit.

Technological aids can help, such as e-mail management software for you, a message-volume regulation system for your organization, or even more-sophisticated solutions being developed by Microsoft, IBM, and others.

Yet, battling technological interruptions on their own turf only goes so far. You also need to change your mind-set, perhaps by seeking help from personal-productivity experts or by simply accepting that you can’t respond to every distraction that flits across your screen. Similarly, organizations must change their cultures, for instance by establishing clear e-communication protocols.

In the end, only a multipronged approach will help you and your organization subdue the multiheaded monster of information overload. The secret is to manage the beast while still respecting it for the beautiful creature it is.

The Idea in Brief

Ready access to information can be at once invaluable and overwhelming, as can the ready access to one another that people have in the information economy.

Technological aids can help to maximize the benefits and minimize the costs to individual and organizational productivity. But changes in mind-set and in company culture are also essential.

Of the many tools and techniques available to manage information overload, none will do the trick on its own. You need a multipronged approach to this multidimensional problem.

Can everyone just stop whining about information overload? I mean, in the knowledge economy, information is our most valuable commodity.

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When is it too expensive? Cost-effectiveness thresholds and health care decision-making

• Published: 05 September 2018
• Volume 20 , pages 175–180, ( 2019 )

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• Pieter van Baal 1 ,
• Job van Exel 1 , 2 &
• Matthijs Versteegh 3  

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The pressure on both tax and insurance-based health care budgets has been high for many years. On the demand side, pressure is increased by an aging population and higher living standards which raise expectations regarding medical services. On the supply side, expensive new health technologies offer new treatment opportunities for patients but often at a (very) high price. Since these high prices are not necessarily a reflection of large health gains, politicians, academics and society need to answer the question when such technologies are ‘too expensive’. When is it justified to not reimburse or use such technologies, effectively limiting supply in collectively financed health care systems? Surely, such a question is not easily answered and draws in subsets of questions from different disciplines, including clinical and ethical angles.

Politically, it may be very difficult to deny an (to some degree) effective treatment option to patients, especially when these patients are in poor health and effective alternative options do not exist. This is strengthened by the fact that in many societies a considerable proportion of citizens display a clear reluctance to accept negative reimbursement decisions, as for many citizens access to health care is seen as a right [ 18 , 30 ], which should not be denied for financial reasons. Footnote 1

Whilst being just one of the relevant academic disciplines to inform this debate, health economics has much to contribute to this important topic, for instance by highlighting the importance of displacement and opportunity costs, by demonstrating the full costs and benefits of new technologies, and by showing how decisions based on such information could be made and argued to be ‘just’ to some extent.

In this editorial, we focus on the latter issue and especially on the question of how a line should be drawn beyond which a technology is considered to be too expensive, and therefore, should not be reimbursed. We will argue that in terms of both theoretical and empirical research, much work remains needed. Moreover, if health economic evaluations are to have more impact on decision-making, interactions with decision makers and the public are required to bridge the gap between academic endeavours and societal and political realities.

When it is too expensive?

From an economic viewpoint, the point at which something becomes too expensive is related to the objective function of a decision maker and the constraints he or she faces. Interestingly, these decision rules differ across jurisdictions, including those jurisdiction that use economic evaluations to inform their decisions. A first important distinction in this context is the objective and perspective of the relevant decision maker. Some jurisdictions, such as Wales and England, take a health care perspective in which the goal is to maximize health from a fixed budget. The decision maker thus aims to produce as much health as possible for the population (often measured as Quality Adjusted Life Years or QALYs) from the fixed budget allocated to health care. Other jurisdictions, like The Netherlands, take a broader societal perspective, in which the goal is to maximize social welfare from a more flexible budget. In the latter context, broader impacts on society, that fall outside the health care sector, are also included in the decision-making process. Below we describe both the societal and the health care perspective on thresholds beyond which technologies are deemed too expensive, in that order.

In the context of the broader societal perspective, the decision rule, firmly rooted in welfare economics (e.g. [ 19 ]), can be written as [ 16 ]: Footnote 2

In which v Q denotes the consumption value of health, Δ Q the incremental gain in health (measured in QALYs) and Δ c t the incremental total costs. Note that Δ c t denotes the total of both health care costs (Δ c h ) and broader consumption costs (Δ c c ), so that Δ c t  = Δ c h  + Δ c c . Equation ( 1 ) can be rewritten as:

This equation shows the incremental cost-effectiveness ratio (ICER) on the left-hand side and simply states that the incremental costs per gained unit of health gain (QALY) should not exceed the consumption value of this unit of health. In practice, this is translated into the question whether the ICER exceeds the monetary value of the QALY. From equation ( 1' ) it is also clear when something is ‘too expensive’. This is the case when the costs per QALY are higher than the value per QALY. It is intuitive that ‘paying’ more for something than its worth will result in a welfare loss. Hence, in this decision context v Q is the relevant threshold determining when something becomes too expensive.

As an aside it needs noting that this value is compared to costs per QALY. It deserves emphasis that prices are not equal to costs but may include (substantial) profits. In other words, paying up to the value ( v Q ) per QALY means that the full welfare surplus created by a technology is transferred from consumers to the producer of a technology. It is questionable whether such a division of surplus is optimal or fair, in particular in the health care context. Value-based pricing should, therefore, not be interpreted as implying that transferring all surplus to producers is necessary, normal, optimal or fair [ 15 ].

Using the same notation, the decision rule related to the narrower health care perspective, assuming a fixed health care budget, can be written as:

in which k is the marginal cost-effectiveness of current spending in the health care system [ 11 ], and only health care costs (Δ c h ) are considered. Ideally, k represents the cost-effectiveness ratio of the interventions that get displaced (given the fixed budget) because of funding the new intervention ( k  = Δ c hd /Δ Q d ). Equation ( 2 ) can be rewritten to

This simply means that the cost-effectiveness of the new intervention should be better than the cost-effectiveness of the displaced care. This is equivalent to stating that the new technology should produce more health per invested euro than it displaces. Hence, under this decision rule k is the relevant threshold value determining when a technology becomes too expensive. Footnote 3

In principle, one would expect k to be equal to v Q , as this theoretically would yield an optimal budget for health care. Whenever the health care budget is fixed and non-optimal (so that k  ≠  v Q ), k will be relevant next to v Q , also in the context of a broader societal perspective and maximizing welfare [ 10 ]. The relevant equation for the broader societal perspective, which can still be extra-welfarist [ 8 ], then becomes:

It is easy to see that Eq. ( 3 ) turns into Eq. ( 1 ) again when v Q  =  k and that it contains Eq. ( 2 ) between the brackets. Using this broader framework also allows the operationalisation of a two-perspective approach, as has been advocated before [ 7 , 26 ]. This would increase comparability between jurisdictions and highlight situations in which both perspectives lead to different conclusions.

Equation ( 3 ) simply states that the value of the net gain in health, that is the gains of a new technology minus the lost health due to displaced care, should outweigh the consumption costs incurred. If the displaced technology is also assumed to be associated with broader societal costs or gains (e.g. productivity costs or informal care), Δ c c should represent the net change of the new activity compared to the displaced activity (see e.g. [ 1 ]). Given that the optimality of health care budgets has not been established, information on k and v Q is required to determine whether or not something is too expensive. So what do we know about these quantities?

First of all, it is striking to see how much research attention has been devoted to the development of methodologies for estimating the left-hand side of Eqs. ( 1’ ) and ( 2’ ), and how little attention the right hand side has received. One could say, we have become better and better in producing estimates of incremental cost-effectiveness of new technologies, but still have fairly little idea about what to compare these figures to. Of course, a comparison of ICERs between different interventions also provides information, but the final judgement of whether something is worthwhile requires knowledge of k and/or v , depending on the applied decision rule. Hence, the imbalance between academic resources allocated to calculating ICERs as compared to determining the threshold to which ICERs ought to be compared to is a worrying issue. In other words, as an academic field, we should be as concerned with estimating the monetary value of the QALY and the cost-effectiveness of displaced health care, as we are with the estimation of ICERs. Fortunately, in recent years, the attention for the right-hand side of the equation appears to be increasing.

In terms of v , the monetary value of the QALY, several studies have produced estimates of v . Commonly, this is done through stated preference techniques, like willingness to pay studies. It needs emphasis that the methodological problems related to such studies, especially for difficult to value goods like health, are well known (e.g. [ 6 ]). In that sense, measurement of v remains highly challenging.

Ryen and Svensson [ 25 ] provide a review of the literature, which highlights substantial variation in produced estimates, with a (trimmed) mean of around 75,000 euros. Interestingly, the amount was related to the size of the gain and higher for life extensions than for quality of life improvements. The latter issues do not only raise questions about the relationship between WTP for health gains and the QALY model, but also to the appropriate perspective to take in order to find v. For example, quite some attention has been paid in the literature to ‘equity weights’ for QALY gains (e.g. [ 21 , 22 ]). People have for instance been shown to prefer QALY gains in younger and more severely ill patients, although the evidence is mixed [ 24 , 32 ]. Such equity weights may be seen as different social values attached to different QALY gains [ 5 , 33 ].

In the Netherlands, a maximum ‘ v -threshold’ of €80,000 is used in decision-making. This threshold is only used for treatments targeted at diseases that cause a very high proportional loss of remaining health [ 24 ]. For less severe diseases, the v -threshold is lower, going down to €20,000 in case of mild diseases (and even zero for very mild diseases—implying that treatments for very mild diseases should not be publicly funded). Such thresholds intend to reflect a societal willingness to pay (WTP) rather than an individual one and may, therefore, express equity concerns [ 4 ]. Most empirical studies estimating v, however, estimate individual WTP estimates for own health gains. It remains unclear how these relate to societal decision-making. The use of a threshold range in relation to disease, treatment or beneficiaries’ characteristics also shows that one unique value of a QALY may not exist [ 9 ].

If so, it would be better to write Eq. ( 1’ ) as Δ c t /Δ Q i  <  \({v_{{Q_i}}}\) so that a specific social value \({v_{{Q_i}}}\) is attached to specific (classes of) QALY gains; Q i . Finding such values, in relation to equity weights, is an important and difficult challenge. Note that end-of-life considerations in the UK or absolute shortfall considerations in Norway, indicate the international relevance of this issue [ 20 , 23 ], as well as a lack of international consensus on how to operationalize equity considerations. Arguably, equity weights should be a reflection of country specific preferences.

An increasing number of studies aims to produce estimates of k , the opportunity costs of health care spending. This is done by considering the (average) marginal gains of increased health care spending. The estimates produced in the UK undoubtedly attracted most attention. The results there showed an average ‘central’ estimate of k of almost £13,000 or ~ €17,700 [ 12 ]. More recently, estimates for Spain and Australia were presented which ranged between €22,000–€25,000 and AUD20,758 (~ €13,250)–AUD37,667 (~ €24,100) respectively [ 14 , 31 ]. In the Netherlands, investigating the marginal returns of spending on cardiovascular treatments in hospitals yielded an estimate of k of about €41,000 [ 29 ]. These findings, acknowledging the uncertainty and measurement issues around estimates of v and k , suggest a discrepancy between these ‘reference ICERs’ and commonly used thresholds (with the latter being higher) as well as between v and k . Given the relevance of k in decision-making, potentially also when using a broad societal perspective, this highlights the importance of more research in this area.

In terms of the discrepancy between k and v, a number of observations must be made. First of all, if v is a range related to equity considerations rather than a single estimate, the comparison of v to k also requires knowledge on the relative distribution of different ‘equity types’ of QALY gains. If relatively many interventions are targeted at areas with an average or low equity weight (e.g. based on disease severity), the observed k may be more in line with v than otherwise implied. In the Dutch case, where a range is proposed for decision-making of zero to €80,000 (e.g. [ 24 ]), the recent Dutch estimate of k of €41,000 [ 29 ] falls within that range and may relate to the value of health gains with an ‘average’ equity weight or value. Second, the estimates for k are based on public expenditures and hence present implicit societal valuations of health gains rather individual valuations. This hampers a direct comparison with common estimates of v which typically take an individual perspective [ 5 ]. On the other hand, Bobinac et al. [ 4 ] did investigate societal valuations of health gains, and found that people were willing to pay up to €52,000 per QALY for gains in others (i.e. gains that would not accrue to themselves) and €83,000 per QALY when the gains were in either others or themselves. Third, k is an estimate of a mean, with health care interventions potentially being both much more and much less cost-effective than represented in the average, making k mostly relevant when it is unknown which health care is displaced. Estimates of k may differ across disease areas and patient subgroups, which is important to consider, also in the context of social decision-making and equity weights. In that sense, it may be better to investigate k j with subscript j indicating relevant health care sectors or disease characteristics. Estimates in the UK show clear differences in productivity of current spending across diseases [ 12 ].

The apparent discrepancy between v and k does raise interesting questions, which deserve more theoretical and empirical attention. In theory, and with perfect estimates, it would signal that health budgets should be increased (so that k would move up to v ). Before recommending this, more evidence on and understanding of both quantities and their relation is needed. For example, one might argue that the size of health care budgets is the consequence of deliberate allocation decisions by a democratically elected body and hence reflects a ‘revealed societal preference’ for resource allocation, also across competing budgets for public spending. Better understanding of why society accepts different levels of efficiency in different health care sectors or disease areas is also important. We note that good comparisons may require broader outcome measures than QALYs, in that context, as well as knowledge about their value. Estimates of willingness to pay for QALY or wellbeing gains may or may not be considered superior as a source to inform about the optimality of budgets across sectors of public spending.

Two right hands!

Given the increased use of economic evaluation and the need to compare ICERs to a relevant threshold value to judge whether or not the technology helps to optimize health or welfare, better understanding and more precise estimates of both v and k , also in relation to each other and to equity consideration, are required. Although the attention is increasing, too much remains unclear about both quantities.

For k, a better understanding involves more and better estimates of opportunity costs in the health care sector. Ideally, these would be accompanied by more information about the process and the extent of disinvestment, opportunity costs in different sectors (hospital versus primary care) and scalability of current programs. Differences in marginal cost-effectiveness between health care sectors may suggest inefficiencies within the health care sector, or additional constraints [ 28 ]. Moreover, it would be interesting to see whether differences between disease areas and sectors in terms of marginal cost-effectiveness reflect societal preferences, including equity considerations. Comparing such k values to sector or disease-specific v values would also be an interesting avenue for future research.

For v , the need for better individual and societal estimates of the monetary value of health gains remains important. Current estimates vary, also due to differences in methodology. New ways of deriving monetary valuations for health gains could be explored (e.g. [ 2 , 27 ]), if only for validation and better understanding of findings from more commonly applied methods. Further exploration of societal valuations would involve the inclusion of information relevant for equity considerations [ 33 ] and require the selection of appropriate equity concepts and appropriate inclusion in economic evaluation (e.g. [ 13 ]). This can also be more directly relevant for policy making and current decision-making frameworks, like the one currently used in The Netherlands.

Comparing k and v and better understanding the discrepancies between them remains important as well. Here, it is important to consider that if equity considerations play a role, the distribution of types of care and QALY gains may matter in the comparison. To illustrate this point, consider the Dutch decision framework with values ranging between 20K€ for interventions in the context of ‘low disease burden’ and 80K€ for ‘high disease burden’, with disease burden measured in terms of proportional shortfall [ 24 ]. Footnote 4 If most QALYs are gained through interventions targeting diseases with a low burden, the relevant v to compare an observed k to would be closer to 20K€ than to 80K€. Moreover, low observed ICERs in the context of primary care and prevention compared to hospital care may, to some extent, reflect similar distributional concerns.

Link to policy and society

A final noteworthy issue is the acceptance of any threshold, be it k or v , in society. It is clear that negative reimbursement or funding decisions typically are not well received in society, and consequently, in the political arena. This is especially the case when the intervention is to some extent effective but not cost-effective. Highlighting the health opportunity costs of reimbursement of a cost-ineffective intervention may provide somewhat more support, as a health versus health trade-off may be more acceptable to some than a health versus money trade-off. Even then, it is important to recognise that the viewpoint of the general public towards rationing may be distinct from health economic reasoning or even an adopted and politically endorsed decision-making framework. A recent European study highlighted that a majority of Europeans consider health care to be ‘a right’ [ 18 , 30 ]. Notions of opportunity costs and limited budgets may not be part of the discourse of many citizens when thinking about choices in health care. In that sense, improving the connection between decision-making and public opinion/support for negative decisions remains highly important.

The decision-making process and policy instruments used in that context may also matter. Depoliticising the decisions on reimbursement of individual treatments, by giving the authority for these decisions to an independent organisation rather than for instance a ministry of health, may help to reduce the political pressure on every single decision, may contribute to more consistent decisions making, but may also be perceived as diminishing political accountability for societal decision-making. Policy instruments like price negotiations (compared to immediate decisions based on the proposed price) may help as well. These can also alter the public perception of who is to ‘blame’ for a negative decision. An accountable process of decision-making, in which broader considerations (e.g. ethical) are weighted by appropriate persons, potentially including patients and citizens, may also improve societal acceptance of decisions. These processes may require involvement of stakeholders during the process prior to evidence generation to make sure all data relevant to the decision-making process is collected.

Policy makers need to be aware of the fact that having explicit thresholds may invoke strategic pricing behaviour by firms, resulting in prices that yield ICERs close to the threshold [ 17 ]. Price negotiations need to focus on a fair distribution of surplus. When a discrepancy between v and k exists, the lower value of the two would be the logical maximum threshold to consider as starting point in price negotiations.

If ICER calculations, thresholds and decisions based on these are to have impact on actual funding and reimbursement, stronger societal support or acceptance seems required. Otherwise, assessing that something is too expensive may not be translated into actual policies.

For deciding whether something is too expensive, thresholds are crucial. Depending on which perspective is taken, the word ‘threshold’ may either refer to the consumption value of health or the marginal cost-effectiveness of current spending. The fact that currently the same word is used for two distinct concepts is not particularly helpful in terms of clarity of discussions. It would be preferable to be precise in what we mean by using distinct terms like k -threshold and v -threshold or supply-side threshold ( k ) and demand-side threshold ( v ). It also needs recognition that in a broader societal decision-making framework, allowing non-optimal budgets, both v and k are relevant. Using a two-perspective approach has many advantages, among which the clear necessity to gather more information on v and k . Better understanding of and evidence on both quantities would also involve their context specificity, especially in relation to equity. Given current evidence, a discrepancy between k and v may well exist, which would lead to new scientific and societal questions.

For now, it seems clear that the question on when something is too expensive remains difficult to answer unambiguously. We particularly advocate more research to explore the right hand side of the equations, that is, v and k . At the same time, more effort to include societal considerations in appraisals, as well as improving the societal understanding and acceptance of the need for and nature of economic evaluations in health care remains highly important. Not knowing when interventions are too expensive, or not accepting this as a reasonable argument for decision-making, is a situation that, for both our future health and wealth, will turn out to be too expensive.

This does not imply that the same people are willing to pay the premium increases that logically follow from this viewpoint.

For simplicity focused on technologies with only current costs and benefits.

Note that the choice for a particular decision rule also has consequences for other methodological choices, e.g. discount rates [ 11 , 3 ].

This means the proportion of health lost due to the disease the intervention is targeted at.

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Acknowledgements

The authors acknowledge the funding was received by The Netherlands Organisation for Health Research and Development (ZonMW), Grant number 1520020381. We especially thank the support and patience of Dr. Benien Vingerhoed-Van Aken.

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Brouwer, W., van Baal, P., van Exel, J. et al. When is it too expensive? Cost-effectiveness thresholds and health care decision-making. Eur J Health Econ 20 , 175–180 (2019). https://doi.org/10.1007/s10198-018-1000-4

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A Stanford education researcher found that too much homework can negatively affect kids, especially their lives away from school, where family, friends and activities matter.   "Our findings on the effects of homework challenge the traditional assumption that homework is inherently good," wrote Denise Pope , a senior lecturer at the Stanford Graduate School of Education and a co-author of a study published in the Journal of Experimental Education .   The researchers used survey data to examine perceptions about homework, student well-being and behavioral engagement in a sample of 4,317 students from 10 high-performing high schools in upper-middle-class California communities. Along with the survey data, Pope and her colleagues used open-ended answers to explore the students' views on homework.   Median household income exceeded $90,000 in these communities, and 93 percent of the students went on to college, either two-year or four-year.   Students in these schools average about 3.1 hours of homework each night.   "The findings address how current homework practices in privileged, high-performing schools sustain students' advantage in competitive climates yet hinder learning, full engagement and well-being," Pope wrote.   Pope and her colleagues found that too much homework can diminish its effectiveness and even be counterproductive. They cite prior research indicating that homework benefits plateau at about two hours per night, and that 90 minutes to two and a half hours is optimal for high school.   Their study found that too much homework is associated with:   • Greater stress : 56 percent of the students considered homework a primary source of stress, according to the survey data. Forty-three percent viewed tests as a primary stressor, while 33 percent put the pressure to get good grades in that category. Less than 1 percent of the students said homework was not a stressor.   • Reductions in health : In their open-ended answers, many students said their homework load led to sleep deprivation and other health problems. The researchers asked students whether they experienced health issues such as headaches, exhaustion, sleep deprivation, weight loss and stomach problems.   • Less time for friends, family and extracurricular pursuits : Both the survey data and student responses indicate that spending too much time on homework meant that students were "not meeting their developmental needs or cultivating other critical life skills," according to the researchers. Students were more likely to drop activities, not see friends or family, and not pursue hobbies they enjoy.   A balancing act   The results offer empirical evidence that many students struggle to find balance between homework, extracurricular activities and social time, the researchers said. Many students felt forced or obligated to choose homework over developing other talents or skills.   Also, there was no relationship between the time spent on homework and how much the student enjoyed it. The research quoted students as saying they often do homework they see as "pointless" or "mindless" in order to keep their grades up.   "This kind of busy work, by its very nature, discourages learning and instead promotes doing homework simply to get points," said Pope, who is also a co-founder of Challenge Success , a nonprofit organization affiliated with the GSE that conducts research and works with schools and parents to improve students' educational experiences..   Pope said the research calls into question the value of assigning large amounts of homework in high-performing schools. Homework should not be simply assigned as a routine practice, she said.   "Rather, any homework assigned should have a purpose and benefit, and it should be designed to cultivate learning and development," wrote Pope.   High-performing paradox   In places where students attend high-performing schools, too much homework can reduce their time to foster skills in the area of personal responsibility, the researchers concluded. "Young people are spending more time alone," they wrote, "which means less time for family and fewer opportunities to engage in their communities."   Student perspectives   The researchers say that while their open-ended or "self-reporting" methodology to gauge student concerns about homework may have limitations – some might regard it as an opportunity for "typical adolescent complaining" – it was important to learn firsthand what the students believe.   The paper was co-authored by Mollie Galloway from Lewis and Clark College and Jerusha Conner from Villanova University.

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