Abstract
Comparative full economic evaluations are needed to evaluate whether telehealth-based systems can bring societal cost savings and economic benefits that exceed economic costs. However, economic evaluations of telehealth-based interventions across different health care fields have focused primarily on cost analysis, rather than on full economic analysis, which captures both the economic costs and economic benefits of two or more competing interventions. The authors provide a framework for Benefit-Cost Analysis that would render this method more applied. In particular, they are interested in the comparative economic evaluation of two categories of Autism Spectrum Disorders intervention programs: telehealth-based and in-person. Their framework can be used to economically evaluate whether telehealth service delivery offers greater societal net benefits—the difference between societal economic benefits and societal economic costs—than in-person delivery, and the threshold volume of telehealth encounters required for the telehealth delivery to reach a zero societal net benefit.
TopIntroduction
Economic evaluations of telehealth-based interventions have focused primarily on cost analysis – a partial economic analysis – rather than on economic analysis that captures both the economic costs and economic benefits – a full economic analysis – of two or more competing telehealth and/or in-person interventions. The most popular full economic evaluation methods in order of comprehensiveness include: Cost-Effectiveness Analysis (CEA), Cost Utility Analysis (CUA) and Benefit-Cost Analysis (BCA). Although telehealth intervention programs were initiated several decades ago in many health care fields, rigorous full economic evaluation of these programs remains rare (Da’valos, French, Burdick & Simmons, 2009). Reasons for such dearth include: data intensiveness and technical sophistication; multidimensionality of telehealth interventions; lack of funding for large-scale programs (Bashur, Shanon & Sapci, 2005); and reluctance to assign monetary values to health improvement outcomes (Bashur et al., 2005; Rearden, 2005). In addition, when compared to CEA studies, only a few BCA studies exist in the published empirical literature even for in-person service delivery (Drummond, Sculpher, Torrance, O’Brien & Stoddart, 2005). Our goal in this chapter is to provide a framework for BCA evaluation that would render this method more applied. In particular, we are interested in the comparative economic evaluation of two categories of Autism Spectrum Disorders (ASDs) intervention programs: telehealth-based and in-person. Furthermore, our framework could be adapted to other health care fields.
Pervasive Developmental Disorders are classified in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) under five diagnostic categories: autistic disorder, Asperger’s disorder, pervasive developmental disorder–not otherwise specified (PDD NOS), childhood disintegrative disorder (CDD) and Rett syndrome (American Psychiatric Association, 2000). The term ASDs is used to refer to autistic disorder, Asperger’s disorder, and PDD NOS.
While economic evaluations of early and intensive behavioral interventions in ASDs exist (Jacobson, Mulick & Green, 1998; Ganz, 2007; Chasson, Harris & Neely, 2007), we are unaware of any existing full economic evaluation of the use of telehealth service delivery for diagnosis, treatment and management of Autism Spectrum Disorders (ASDs). This may be attributable to the recent introduction of telehealth interventions in ASDs (Terry, 2009). A systematic examination of recent telepractices in ASDs in terms of diagnostic assessments, educational consulting, and guidance and supervision of behavioral interventions concluded that telepractice is a promising service delivery model for individuals on the autism spectrum (Boisvert, Lang, Adrianopoulos & Boscardin, 2010).
The traditional in-person ASD service delivery system has been unable to address the increase in both demand for services and societal costs of caring for people on the autism spectrum1. Telehealth service delivery has the potential to address these challenges. The gradual introduction of individual, large scale, and eventually, system interventions will require full evaluation analysis to economically justify such introduction and its possible widespread adaptation as not only a complementary, but also a competing system to the traditional in-person service delivery.
Key Terms in this Chapter
Applied Behavior Analysis (ABA): A scientific approach for evaluating behavior, which teaches social, motor, and verbal behaviors, as well as reasoning skills. ABA treatment is used in teaching behaviors to children with autism who may not “pick up” these behaviors on their own. The ABA approach can be used by a parent, counselor, or certified behavior analyst.
Cost-Utility Analysis (CUA): A form of economic analysis, which compares costs related to a generic outcome derived from the utility of treatment outcomes that allows for quality of life adjustments, such as QALY or DALY.
Full Economic Evaluation: Economic evaluation that requires identification, measurement, valuation, and comparison of both costs (inputs) and consequences (outputs, outcomes) of alternative health care resources.
Cost-Effectiveness Analysis (CEA): A form of economic analysis, which compares costs related to a single common outcome (in natural units) across alternative programs, by computing a cost/unit of outcome ratio, or an outcome/$ spent ratio.
Quality-Adjusted Life Years (QALY): A measure of health outcomes defined as perfect health minus DALY. QALY combines changes in morbidity (quality) and mortality (amount) in a single indicator.
Disability-Adjusted Life Years (DALY): A quantitative indicator of burden of disease that reflects the total amount of healthy life lost, to all causes, whether from premature mortality or from some degree of disability during a period of time. While one DALY can be thought of as one lost year of “healthy” life, the sum of DALYs across the population represents the burden of disease.
Societal Net Economic Benefit: The difference between economic benefits and economic costs from the combined perspectives of all stakeholder groups affected.
Benefit-Cost Analysis: A form of full economic evaluation analysis, which compares the monetized benefits to the monetized costs across alternative programs, by computing a benefit/cost ratio, or the net benefit, which is the difference between benefits and costs.
Autism Spectrum Disorders (ASDs): Pervasive Developmental Disorders classified under five diagnostic categories: autistic disorder, Asperger’s disorder, Pervasive Developmental Disorder-Not Otherwise Specified (PDDNOS), Childhood Disintegrative Disorder (CDD), and Rett syndrome.
Full Economic Evaluation: Economic evaluation that requires identification, measurement, valuation, and comparison of both costs (inputs) and consequences (outputs, outcomes) of alternative health care resources.
Societal Net Economic Benefit: The difference between economic benefits and economic costs from the combined perspectives of all stakeholder groups affected.
Telehealth: The use of electronic information and telecommunications technologies to support long-distance clinical health care, professional health-related education, public health, and health administration.
Cost-Effectiveness Analysis (CEA): A form of economic analysis, which compares costs related to a single common outcome (in natural units) across alternative programs, by computing a cost/unit of outcome ratio, or an outcome/$ spent ratio.
Cost-Utility Analysis (CUA): A form of economic analysis, which compares costs related to a generic outcome derived from the utility of treatment outcomes that allows for quality of life adjustments, such as QALY or DALY.
Disability-Adjusted Life Years (DALY): A quantitative indicator of burden of disease that reflects the total amount of healthy life lost, to all causes, whether from premature mortality or from some degree of disability during a period of time. While one DALY can be thought of as one lost year of “healthy” life, the sum of DALYs across the population represents the burden of disease.
Applied Behavior Analysis (ABA): A scientific approach for evaluating behavior, which teaches social, motor, and verbal behaviors, as well as reasoning skills. ABA treatment is used in teaching behaviors to children with autism who may not “pick up” these behaviors on their own. The ABA approach can be used by a parent, counselor, or certified behavior analyst.
Autism Spectrum Disorders (ASDs): Pervasive Developmental Disorders classified under five diagnostic categories: autistic disorder, Asperger’s disorder, Pervasive Developmental Disorder-Not Otherwise Specified (PDDNOS), Childhood Disintegrative Disorder (CDD), and Rett syndrome.
SAVE: A measure of health outcomes based on the Person-Trade Off (PTO) technique of estimating the social value of competing health care interventions, which consists in asking people how many outcomes of one kind they consider equivalent in social value to X outcomes of another kind. The magnitude of X determines the social value, which captures distributional and ethical considerations, not accounted for in the QALY approach.
Benefit-Cost Analysis: A form of full economic evaluation analysis, which compares the monetized benefits to the monetized costs across alternative programs, by computing a benefit/cost ratio, or the net benefit, which is the difference between benefits and costs.
Quality-Adjusted Life Years (QALY): A measure of health outcomes defined as perfect health minus DALY. QALY combines changes in morbidity (quality) and mortality (amount) in a single indicator.
SAVE: A measure of health outcomes based on the Person-Trade Off (PTO) technique of estimating the social value of competing health care interventions, which consists in asking people how many outcomes of one kind they consider equivalent in social value to X outcomes of another kind. The magnitude of X determines the social value, which captures distributional and ethical considerations, not accounted for in the QALY approach.
Telehealth: The use of electronic information and telecommunications technologies to support long-distance clinical health care, professional health-related education, public health, and health administration.