Will integration widen income-related health inequalities?

I’ve just returned from Dublin, where I attended the International Health Economics Association’s annual conference. My first reflection is just how far the study of health economics has come in the past 20 years. My only previous exposure to the iHEA conference ‒ in the late 1990s ‒ was dominated by quality-of-life research and studies on the cost-effectiveness of drugs. Whilst there were still sessions on these in Dublin, the health economics research field is much richer, more policy-relevant and increasingly populated by those who have come to health economics from other disciplines. This can only be good for health economics and its impact on policy.

My main reason for being at the conference was to chair two sessions: the first on the return on investment of different public health interventions and the second on inequalities in health. The first session showcased the return-on-investment tools NICE have recently developed for local areas in the fields of tobacco control, alcohol and physical activity. You can find these tools, and the plans to support their use, on the NICE website.

The second session brought together various strands of work on inequalities, including why we need to take account of changes in the population – such as migration, birth and death – when measuring health inequalities in relation to people’s income over time. This is critical when holding governments to account for policy goals such as ‘improving the health of the poorest fastest’ and if we don’t take these population changes into account, we can make erroneous judgments on policy. 

For example, a study of the early 2000s found that increases in income-related health inequalities (measured by quality-adjusted life years or QALYs) were masked by an influx of younger, poorer and healthier than average people entering the population (through births and immigration) and by older, sicker and poorer groups exiting the population (through deaths and emigration).  

This raises the issue of how integrated care may affect the measurement of income-related health inequalities over time. If integration is particularly successful at keeping the poor and sick alive it may worsen income-related inequalities on quality of life measures since, by definition, these groups have a lower quality of life. Although that would clearly be a success for policy, not a failure! Integration would also improve life expectancy statistics for the poor since they would no longer be dying early, and life expectancy income related inequalities would simultaneously improve. The effect on composite outcome measures, such as healthy life expectancy, will be more complex.

In short, we need to be very careful in understanding the links between choice of metrics, impact of policies and population dynamics over time when coming to conclusions about the success or failure of ambitions and policies to narrow inequalities in health.

Outside my sessions, and somewhat surprisingly to me, inequalities and the wider determinants of health were strong themes across the conference, a welcome sign that health economists increasingly see beyond the cost-effectiveness of health care. There were insightful sessions on the impact of the recession on health and an assessment of how important, or not, the wider determinants are on health in different countries. Finally, there was also much that was relevant to the NHS funding debate, including the impact of changes to how NHS resources are allocated to address inequalities and a reassessment of what drives NHS costs. In short, the presence of co-morbidities may drive more NHS costs than both ageing and the costs that accrue, at whatever age, in the few months or weeks before a person’s death.

So overall, watch this space, much of what was presented is work in progress, but there is no doubt the health economists are coming, and with more interesting things to say than you might expect. 

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