Author: Ana Durán
The sustainability of healthcare systems largely depends on making informed decisions about which technologies to adopt, fund, or disinvest. In this context, health technology assessment becomes an essential tool for comparing alternatives. One of its pillars is cost analysis, which estimates the resources needed to implement a health technology. But what do we mean by “cost,” and how is it classified?
What do we mean by cost in health technology assessment?
In this context, cost is not limited to the purchase price of a product or service. It refers to the monetary value of all resources consumed throughout the life cycle of a healthcare intervention: from acquisition to implementation, follow-up, and potential adverse effects.
For example, the cost of a medical device not only includes its purchase price but also the time of healthcare personnel for its use, necessary training, maintenance, and costs derived from its impact on patient health.
How do we classify costs?
Costs can be classified according to different criteria:
a) By the origin of the resource (1):
- Direct healthcare costs: These include costs related to healthcare resources in disease management, such as medications, medical devices, surgical procedures, medical visits, diagnostic tests, consultations, hospitalizations, etc. They are the most visible and easily quantifiable.
- Direct non-healthcare costs: These include costs of resources not strictly clinical but related to the condition, relevant to patients and society, such as transportation to healthcare facilities, accommodation for health reasons, formal care (professional) or informal care (by unpaid family members or caregivers), and home adaptations.
- Indirect costs: These refer to productivity losses for the patient and informal caregiver due to disease management, disability, or premature death.
- Intangible costs: These represent subjective aspects such as pain, suffering, anxiety, or loss of quality of life. Although difficult to monetize, they can be addressed through utility measures such as QALYs (quality-adjusted life years).
b) By the perspective of the analysis: The perspective defines which costs are included. The most common are (1):
- Healthcare system: Considers only costs borne by the public system.
- Payer (insurer, hospital): Similar to the previous one but focused on the specific funder (e.g., an insurer or the NHS). It may exclude costs borne by the patient or society.
- Society: The broadest and most comprehensive perspective. It includes all types of costs (direct, indirect, intangible), regardless of who bears them. It is considered the most appropriate for decisions affecting overall population well-being.
- Patient: Includes costs directly affecting the user, such as co-payments, out-of-pocket expenses, travel, time invested, or care not covered by the system.
Which cost perspective is most used in Spain, and what types of costs are included in health technology assessment?
In Spain, most economic evaluations, cost studies, or burden-of-disease studies conducted for public decision-making adopt the perspective of the National Health System, meaning only direct healthcare costs are considered. This choice aligns with the NHS’s budgetary logic, which seeks to optimize resource use within its scope.
However, in recent years, interest in adopting a societal perspective has grown, especially in analyzing chronic, rare diseases or those with a high impact on quality of life. Including indirect and non-healthcare costs allows for better capturing the real value of interventions, particularly those that improve autonomy, reduce dependency, or enable return to work.
References
1. Drummond MF, Sculpher M, Claxton K, Stoddart GL, Torrance GW. Methods for the economic evaluation of health care programmes. Fourth edition. Oxford: Oxford University Press; 2015. 1 p.
