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비용-효과 임계값은 무엇을 반영하여야 하나?

What should the cost-effectiveness threshold reflect?

배은영
한국보건경제정책학회 (The Korean Association of Health Economics and Policy)|2018.06|보건경제와 정책연구 (The Korean Journal of Health Economics and Policy)|제24권 제2호|pp. 83-106

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키워드

Willingness to Pay지불의사기회비용Opportunity Cost비용-효과 임계값Cost-Effectiveness Threshold
주제분류사회과학일반

초록

비용-효과 분석에서 임계값은 해당 대안의 비용-효과성을 판단하는 기준이 되는 값이다. 많 은 나라에서 임계값 수준을 명시적으로 밝히고 있지 않으나, 비용-효과성에 대한 판단을 위해 서는 적정 임계값의 사용이 매우 중요하다. 본 연구에서는 임계값이 무엇을 반영하여야 하는 지에대한서로다른관점을소개하고, 서로다른관점하에서이루어진임계값추정치를비 교하였다. 아울러각관점을채택할경우우리나라의적정임계값수준이어느정도가될것 인지에 대해서도 선행연구를 바탕으로 논의하였다. 임계값이 무엇을 반영하여야 하는지와 관 련하여 크게 건강개선에 대한 지불의사를 반영하여야 한다는 입장과 기회비용을 반영하여야 한다는 주장이 있다. 지불의사 조사를 통해 임계값을 설정해야 한다고 주장하는 논자들은 그 것이 사회가 건강에 부여하는 한계가치를 반영한다고 주장한다. 반면 기회비용을 반영하여 임 계값을 설정해야 한다고 주장하는 논자들은 기회비용을 고려하지 않은 결정으로 그 사회의 총 건강 수준이 오히려 감소될 수도 있다고 주장한다. 지불의사는 총 보건 예산의 증감을 논할 때는 의미가 있으나, 개별 기술들에 대해 평가하고 급여여부를 결정하는 단계에서는 맞지 않 다는 것이 이들의 주장이다. 우리나라에서는 현재 1인당 GDP를 의사결정의 기준으로 암묵적 으로 사용하고 있고, 지불의사에 대한 선행 연구 결과도 1인당 GDP의 임계값을 대체로 뒷받 침한다. 그러나 기회비용 관점에 입각하여 적정 임계값 수준을 도출할 경우, 이 수준은 1인당 GDP에 비해 낮게 나타난다. 물론 이 값은 다른 나라에서 이루어진 연구에 각 나라의 GDP 수 준의 차이를 반영한 것으로, 많은 가정과 단순화에 기초하여 도출된 값이다. 따라서 적정 임계 값 수준이 어느 정도인지에 대해 아직은 뚜렷한 결론을 도출할 수는 없으나 잘못된 기준의 적 용이 오히려 총 건강을 감소시킬 수 있음을 고려한다면 임계값 조정에 주의가 필요하다.

Abstract

The cost-effectiveness threshold is the basis for judging whether alternative A is cost-effective or not. Although many countries do not explicitly disclose their threshold levels, the use of an appropriate threshold is critical for efficient resource allocation. In this study, different views will be examined regarding what thresholds should be reflected. There is a claim that the threshold should reflect the opportunity cost of implementing new technologies. However, the thresholds applied in many cases are based on the willingness to pay for additional life years accrued by new technologies. The WHO threshold also takes the willingness to pay into consideration. Those who argue that thresholds should reflect opportunity costs insist that those decisions which do not take opportunity costs into account can rather reduce the total health level of the society. In Korea, per capita GDP, was used as a criterion for judging cost-effectiveness in reimbursement decision-making. Previous research results on the willingness to pay for additional QALY also generally supports this threshold level. However, if the threshold level is derived from an opportunity cost perspective, it is calculated to be 46~52% of GDP per capita. This value is an update on previous research results that reflect the difference in GDP levels of each country. In the process, however, many assumptions were used, thus it is not possible to draw clear conclusions about the level of the appropriate cost-effectiveness threshold. Nevertheless, care should be taken when adjusting the threshold value, considering that the application of the wrong criterion may instead reduce the overall health of beneficiaries.

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