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Health Economics in Rheumatology: A Felt Need in India

1 Department of Rheumatology, Deenanath Mangeshkar Hospital, Pune, Maharashtra, India
2 Departement of Rheumatology, Centre for Rheumatology, Kozhikode, Kerala, India

Date of Submission20-Nov-2022
Date of Acceptance22-Nov-2022
Date of Web Publication13-Dec-2022

Correspondence Address:
Vinod Ravindran,
Centre for Rheumatology, Kozhikode - 673 009, Kerala
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/injr.injr_197_22

How to cite this URL:
Ekbote GG, Ravindran V. Health Economics in Rheumatology: A Felt Need in India. Indian J Rheumatol [Epub ahead of print] [cited 2023 Feb 2]. Available from:

Health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.[1] Health economics is a branch of economics concerned with issues related to efficiency, effectiveness, value, and behavior in the production and consumption of health and health care. Health economics is important in determining how to improve health outcomes and lifestyle patterns through interactions between individuals, health-care providers, and clinical settings. Simply put, health economics is the discipline of economics applied to the topic of health care.[2]

Health improvement is one of the most important social priorities. However, health-care expenditure widely varies among developing countries. It also varies from the private sector to the public (governmental) sector. In India, people who avail treatment from health-care providers in the private setup usually are self-funded or avail health insurance policies paid for either by self or the companies they work for. Whereas in public sectors, the treatment-related costs by and large are borne by the government. However, there is a lot of disparity in the quality of the health-care provided in these two different setups.

It is apparent from the foregoing discussion that a peculiar feature of health-care economics is that it does not follow normal rules of economics. Price and quality of health care are often hidden by the third-party payer system utilizing insurance companies and for those who are self-funded, they are a matter of access and preference. In addition, quality-adjusted life years, one of the most commonly used measurements for treatments, is often difficult to measure and relies upon assumptions that may be often deemed unreasonable.[3] Therefore, “average cost per patient” are not comparable between the studies, unless the sample studied and the methodology used are identical. To overcome these issues, health economics applies the discipline and the methods of economics to the topic of “health.”[4] Let us now consider few pertinent issues particularly relevant to the rheumatology health care in India which impacts health economics in the following couple of paragraphs.

In rheumatology, we deal with conditions ranging from less serious such as fibromyalgia, and gout to moderately serious ones such as rheumatoid arthritis (RA), and spondyloarthropathies to very serious ones such as vasculitis, myositis, and lupus. In general, the more serious is the disease, greater is the financial burden it imposes on the patients and their caregivers.

In our country, it is a standard practice to start conventional disease-modifying antirheumatic drugs (DMARDs) first, especially in RA. However, whenever a patient presents with deforming RA with multiple comorbidities, it is often very difficult to treat such a patient. Although we now have good treatment for RA such as targeted synthetic or biological DMARDs, due to cost constraints, multiple comorbidities, and potential risk of infections, these newer drugs come with financial and clinical limitations. The economic hypothesis applicable to chronic progressive diseases states that the cost increases and quality of life (QoL) decreases as the disease worsens over time. In this context, the concept of early RA and aggressive therapy are geared to halt the disease progression. It follows that, if such treatment is successful in halting the progression of the disease then it would not only save the cost, it is more likely to result in the patient's adherence to the treatment.[5] In RA, the Outcome Measures in RA Clinical Trials group tried to define a reference case economic evaluation for newly developed DMARDs. It was envisaged that a reference case-based economic evaluation would adhere to specific settings with regards to outcomes, comparators, modeling techniques, and use of costs to facilitate comparisons among economic evaluations performed with the same objective.[6]

There are basically two types of analyses which could be applied to RA and potentially other rheumatological diseases; descriptive studies that simply describe what can be observed (positive theory) or evaluative studies that attempt to estimate what would happen if a change (such as a new treatment) to what has been observed is introduced (normative theory).[4] Depending on the requirement, both or any of these studies could be utilized in comparing the health-care economics among different sectors.

As the means and quantities of available resources are finite and not all are often accessible, in rheumatology too, in India, we must prioritize the needs. Hence, we need to have a proper modeling system when we assess chronic rheumatologic diseases and must adopt a long-term view for such diseases as clinical trials just might not be sufficient to show the full effect of a treatment that is required for long term to change the course of the disease. These models could be a structured representation of the otherwise complicated environment that allows different hypotheses and circumstances on a number of outcomes, such as costs and QoL, using the best available information at the time of analyses.[4]

To conclude, health economic-related analyses are an important tool to assess treatment and for policymaking. It is imperative that in India, we embark on a systematic study of health economics in rheumatology. As it has been shown that the different economic models of treatments for RA incorporate different key data inputs and analytic judgments and differences in the choice of model structure and in key assumptions also have a major impact on results, we need to be mindful of the Indian realities in structuring such models for RA and other rheumatological diseases.[7] Another aspect is that in the want of a universally accepted methodology for economic evaluation in rheumatologic diseases, the modeling should be easy for a nonspecialist audience to understand. Furthermore, a concentrated effort in this direction would overcome the limitation of similar modeling studies yielding different results borne out of the technical complexities of those models.[8]

  References Top

Constitution of the World Health Organization. World Health Organization: Basic Documents. 45th ed. Geneva: World Health Organization; 2005.  Back to cited text no. 1
Kernick DP. Introduction to health economics for the medical practitioner. Postgrad Med J 2003;79:147-50.  Back to cited text no. 2
Johnson FR, Scott FI, Reed SD, Lewis JD, Bewtra M. Comparing the noncomparable: The need for equivalence measures that make sense in health-economic evaluations. Value Health 2019;22:684-92.  Back to cited text no. 3
Kobelt G. Thoughts on health economics in rheumatoid arthritis. Ann Rheum Dis 2007;66 Suppl 3:i35-9.  Back to cited text no. 4
Ravindran V, Jadhav R. The effect of rheumatoid arthritis disease education on adherence to medications and followup in Kerala, India. J Rheumatol 2013;40:1460-1.  Back to cited text no. 5
Maetzel A, Tugwell P, Boers M, Guillemin F, Coyle D, Drummond M, et al. Economic evaluation of programs or interventions in the management of rheumatoid arthritis: Defining a consensus-based reference case. J Rheumatol 2003;30:891-6.  Back to cited text no. 6
Drummond MF, Barbieri M, Wong JB. Analytic choices in economic models of treatments for rheumatoid arthritis: What makes a difference? Med Decis Making 2005;25:520-33.  Back to cited text no. 7
Bansback NJ, Regier DA, Ara R, Brennan A, Shojania K, Esdaile JM, et al. An overview of economic evaluations for drugs used in rheumatoid arthritis: Focus on tumour necrosis factor-alpha antagonists. Drugs 2005;65:473-96.  Back to cited text no. 8


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