Cost-effectiveness, pharmaceutical pricing and the value flower - doing some gardening.

During the recent years, ISPOR has proposed a number of values that could be taken into account in health technology assessments, for instance when doing an evaluation of what determines society's price for pharmaceutical treatments. These includes values that are not usually considered in health economic evaluation of pharmaceutical pricing, for instance option value, the value of hope and knowing, insurance value, the value of avoiding contagion, and scientific spillover. If these values were included in assessments of pricing of pharmaceutical, it would lead to broadening the cost-effectiveness analysis. We scrutinize the these suggested new value petals of the so-called value flower from two points of views: ethical value theory and the practical implications for a public healthcare system of a European kind, which factors in considerations of traditional cost-effectiveness (primarily in terms of net cost and quality-adjusted life years) and justice (primarily in terms of severity) from the outset. We argue that some of the suggested value petals should not be included in the health economic assessment for several reasons related to value theory or practical considerations in the welfare state: some are mutually conflicting, some do not point out unequivocally positive values, some entails double counting, some are already included in healthcare systems with universal coverage, or can be better handled by other means than by affecting pharmaceutical pricing. A few new petals have potential merit, for instance equity, but much work, both normative and empirical, is required if they should be included in the assessment of pharmaceuticals.