Spotlight on OHE: Competition in the NHS, HESG, Publications

OHE was active in several forums in June. This blog post summarises the highlights.

Competition in the NHS

Jon SussexJon Sussex was a keynote speaker at the Capita conference on competition in health care held in June, where the audience was primarily from the NHS. Jon’s presentation summarised the state of provider competition in the NHS to date as well as national and international evidence about the impact of competition on quality. Competition would be important for some services, Jon noted, but unimportant for others. Assessing the feasibility of competition is essential using, for example, the framework developed by the OHE Commission on NHS Competition.

OHE at HESG: Health Care Decision Making, Hospital Market Concentration

The Health Economists’ Study Group (HESG) was founded in 1972 to support and promote the work of health economists. Its members are from academic, commercial, and government settings. The purpose of HESG is to transmit knowledge and ideas, ranging from the theoretical to very practical policy issues. HESG meets twice a year, most recently in June 2014.

Two OHE papers were discussed at the most recent HESG meeting.

  1. A paper by Karla Hernandez-Villafuerte and Jon Sussex that sets out a preliminary model intended to characterise the behaviour of decision makers in the health sector who must make choices based on budget constraints set by government or another health system authority. Specifically, the model focuses on the options available when use of new health technology is mandated.

See also the recent OHE Research Paper Opportunity costs of implementing NICE decisions in NHS Wales.

  1. A paper co-authored by Yan Feng, Michele Pistollato, Anita Charlesworth, Nance Devlin, Carol Propper and Jon Sussex that assesses the relationship between market concentration in hospital care and health gains as reported by patients following primary hip replacement surgery. This research is a joint project of OHE and the Nuffield Trust.

June Publications

In June, OHE welcomed two new members to its team, Dr Amanda Chapman and Grace Marsden. Shortly after beginning her position at OHE, a paper on which Amanda is lead author appeared online in Applied Health Economics and Health Policy. The article is based on Amanda’s work on medical devices while at the University of Birmingham and assesses the effect of NICE’s Medical Technologies Evaluation Programme over its first three years of operation[1].

Also just published online is an article by Karla Hernandez-Villafuerte on age and inequalities in access to care[2].

To inquire further, please contact the relevant OHE team member by visiting the About Us section of the website.


[1] Chapman, A., Taylor, C.A. and Girling, A.J., 2014. Are the UK systems of innovation and evaluation of medical devices compatible? The role of NICE’s Medical Technology Evaluation Programme (MTEP). Applied Health Economics and Health Policy. DOI: 10.1007/s40258-014-0104-y.

[2] Hernandez-Villafuerte, K., 2014. El adulto mayor y la universalidad de la salud: Análisis de desigualdad basado en una comparación entre los diferentes grupos de edad. Estudios de Economia Aplicada. [Available in Spanish only.]



Interdependencies in Funding Medical Research in the UK

Exploring the Interdependencies of Research Funders in the UKCancer Research UK has recently released a report completed for it by OHE and the Science Policy Research Unit (SPRU) at the University of Sussex that focuses on the strength and nature of interdependence in the funding of cancer research.

As earlier OHE research has demonstrated, sources of funding for medical research—public, charity and private sector—are complementary in effect, not duplicative. The three sectors also differ in their approaches; reduced funding from one would not only decrease the overall financing available, but also change the nature of the research effort overall. This is a concern given that austerity in government spending in the UK is likely to continue for some time.

OHE and SPRU produced a report for Cancer Research UK to explore two sets of questions:

  1. What are the differences in the research activities supported by various funders in the UK? How complementary and interdependent are they?
  2. If government funding of life sciences research was cut, what would be the effect on life sciences research in the UK? Could other funders compensate for the loss of funds?

The research for the report included the following.

1.  Economies of scale in charity- and publicly-funded medical research in the UK were explored via a literature review, interviews with major UK medical research funders and analysis of cost data provided by those interviewed.

The study found that economies of scale are relatively modest except when research requires particularly specialized and costly equipment and infrastructure.

2. Analysis of the interdependencies and the differences across the research activities supported by the diverse funders of cancer research in the UK. Research publications were examined to gain an understanding of the importance of funders named or acknowledged, including those from outside the UK.

The study found that funding for two-thirds of projects reported in publications routinely came from more than one funder, just under half had funding from outside the UK, and a fifth received funding from industry. The study’s findings reflect the highly collaborative nature of cancer research, with the majority of papers being produced by teams working across organisations and many relying on international co-authorship ties. These ties leverage thousands of national and international funding sources, large and small, to support the 7% of global cancer publications that the UK produces.

3. To explore the connections between government and charity funding of cancer research in the UK, the study included an Internet-based survey of how changes in government funding might affect the general public’s willingness to donate to cancer research charities.

The study found that the general public would not want public funding for cancer research to be reduced, but would also not donate more to compensate for a reduction.

The report concludes that:

Exploring the interdependencies between different medical research funders, particularly in cancer, provides us with a striking picture of the extent to which research funders contribute together to produce world class research. The findings provide a compelling case for why investment—by all sectors—is needed to allow the UK to maximize its research outputs.

Download Shah, K., Sussex, J., Hernandez-Villafuerte, K., Garau, M., Rotolo, D., Hopkins, M., Grassano, N., Crane, P., Lang, F., Hutton, J., Pateman, C., Mawer, A., Farrell, C. and Sharp, T., 2014. Exploring the interdependencies of research funders in the UK. Research Paper 14/03. London: Office of Health Economics.

For additional information, please contact Jon Sussex at OHE. For earlier OHE research on these issues, click here.

The report is also available on Cancer Research UK’s website.




OHE Consulting Report on the Trajectory of Dementia in the UK

The trajectory of dementia in the UK – making a differenceAlzheimer’s Research UK commissioned OHE Consulting to model the growing prevalence and costs of dementia in the UK and the impact that new treatments could have were they to be introduced from 2020.

Today over 800,000 people aged 60 and over are living with dementia in the UK. The risk of developing dementia increases greatly with age, from around 1% of men and 1.5% of women in their sixties to more than a quarter of men and a third of women aged 90 and over. The ageing of the UK population, then, will mean an increasing number of people living with dementia.

Based on the latest official UK population projections and the most authoritative estimates of the prevalence of dementia, OHE Consulting built a model to project the number of people with dementia in the UK to 2050. The model then was used to project the health and social care costs of dementia. The results show that unless ways are found to prevent or cure dementia, the number or people in the UK aged 60 and over who will be living with dementia is likely to double over the next 25 years and reach two million by 2050.

The economic cost to the UK of caring for people with dementia is estimated to grow correspondingly from £24 billion in 2014 to £59 billion (at constant prices) by 2050. A large part of the cost of care is the time given up by informal carers to look after loved ones with dementia; the UK will need around 1.7 million informal carers by 2050 compared to the around 700,000 currently giving care.

OHE’s model shows how new interventions to prevent and treat dementia could radically change this picture. Delaying the onset of dementia by five years in the UK from 2020 could reduce the projected number of people with dementia in 2050 by one third (666,000) and reduce the need for informal carers by 566,000; costs of care would be £21 billion lower in 2050 (£38 billion rather than £59 billion).

Even if it were not possible to delay the onset of dementia, slowing the rate at which it progresses – from mild to moderate to severe – would bring major improvements in quality of life and less premature mortality from dementia.

Download Lewis, F., Schaffer, S.K., Sussex, J., O’Neill, P. and Cockcroft, L., 2014. The trajectory of dementia in the UK – making a difference. Consulting Report. London: Office of Health Economics.

For additional information, please contact Jon Sussex at OHE.

 For an associated policy report by Alzheimer’s Research UK click here.


Spotlight on OHE: NICE, Biosimilars, HTA

OHE’s active involvement in a number of recent conferences and meetings has contributed to discussions on a range of important issue in health economics.

 Changes in NICE decision making

The consultation process for changes in how NICE assesses the value of a health technology is scheduled to be completed in June 2014. In a presentation at the PharmaAccess Leader’s Forum, Martin Garau summarised the proposed changes that are part of the value based assessment consultation. She illustrated how two suggested decision-making factors, burden of illness and wider societal impact, might be measured and calculated for specific interventions.

For a comprehensive reviews of OHE’s extensive publications and research on NICE, click here.

For additional information about this presentation, please contact Martina Garau.

HTA and Biosimilars

At the 34th Spanish Health Economics Association annual meeting, Jorge Mestre-Ferrandiz reviewed the results of the discussions of an expert panel about the role of HTA for biosimilars. Representatives from the three UK HTA agencies, the MHRA and academia were involved in debating which HTA methods are most appropriate for biosimilars in specific situations.

The results of the roundtable also are available on this website as an OHE Briefing.

For additional information, please contact Jorge Mestre-Ferrandiz.

HTA in Latin America

In a poster presentation at the 34th Spanish Health Economics Association annual meeting, Karla Hernandez-Villafuerte presented the first stage of research into the pharmaceutical market in Latin America. The poster presentation demonstrated the variety of approaches across countries and the importance of HTA.

For additional information, please contact Karla Hernández-Villafuerte.




Implementing NICE Decisions in Wales: Opportunity Costs

Opportunity Costs of Implementing NICE Decisions in NHS WalesJust out is a new Research Paper from OHE that examines how local NHS organisations in Wales adjust spending to accommodate ‘shocks’ such as new NICE mandates for covering specific technologies.

By law, technologies recommended by NICE are to be funded within three months of publication of NICE’s technology appraisal (TA) decision. Explicit in NICE’s approach to health technology assessment (HTA) is the assumption that new, cost-increasing technology will displace spending on existing, less cost-effective health care. To date, however, no research has explored whether this happens in practice, which is important in understanding the actual effects of NICE’s use of HTA. In this Research Paper, the authors seek to document experience in NHS Wales and review how budget holders set priorities for spending.

Semi-structured interviews were completed with finance directors and/or medical directors from all seven Local Health Boards (LHBs) in NHS Wales. These interviews covered processes for setting priorities and approaches to dealing with sudden financial demands, or ‘shocks’, such as new NICE TAs, for the period October 2010 – March 2013.

The study found that the financial impact of NICE TAs is generally anticipated and planned for in advance and that the majority of LHBs have contingency funds available to cope with these and other ‘shocks’. Efficiency savings, i.e. reductions in costs with no expected reductions in quality, were a major source of funds for dealing with cost pressures of all kinds. Additionally, the Welsh Government has acted as the funder of last resort on occasion. Service displacements, moreover, could not be linked to particular NICE TAs.

The authors conclude that: ‘Services may be displaced as part of a response to the cumulative impact of all types of cost pressures, including cost-increasing health technologies newly recommended by NICE, but such displacements were not direct responses to the publication of individual NICE TAs.’ Cost pressures from new NICE TAs were likely to be accommodated at least in part by greater efficiency and increased expenditure.

Download Schaffer, S.K., Sussex, J., Hughes, D. and Devlin, N., 2014. Opportunity costs of implementing NICE decisions in NHS Wales. Research Paper 14/02. London: Office of Health Economics.

For additional information, please contact Sarah Karlsberg Schaffer at OHE.


OHE’s Adrian Towse to Take Office as ISPOR President

Towse speaking LI 2-24-14

Adrian Towse

OHE’s Director, Adrian Towse, is President of the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) for the 2014–15 term, beginning 1 July. His 3 June incoming president’s address to the plenary session at the 19th Annual International Meeting is reproduced below. 

ISPOR Incoming President’s Remarks

When I stood for election as President of ISPOR, I set out my view of the challenges ISPOR must address:

1. Continuing to globalise, by which I mean responding to the reality that most of the growth of interest in outcomes research and economic analysis is taking place outside North America and Europe

2. Working together with payers, who are demanding greater evidence of value, to establish what is feasible, given data, costs and the science and, over time, improve methods, the evidence base, and decision making

3. Continuing to raise scientific standards for health economics and outcomes research and

4. Supporting the next generation of researchers, by providing forums and opportunities both for learning and for exchanging important new ideas and approaches.

This meeting sets a record for the number of attendees at a North America ISPOR meeting and includes participants from a record number of different countries, a record number of student chapters, and regional chapters; the Asia Consortium is celebrating its first decade, the Latin American Consortium is celebrating ten years next year, and the Arabic and African chapter is looking to achieve Consortium status. Clearly, then, ISPOR is addressing important challenges, but I want to say a little more about the first challenge, globalisation.

  • Globalisation of ISPOR must be linked to an understanding of decision making in middle- and low-income country (MLIC) health systems.
  • MLICs increasingly wish to achieve universal health coverage (UHC) for their populations.
  • Using HTA, economic analysis and outcomes research to support priority setting as part of UHC will be important.
  • A key challenge in HTA in these, and indeed all regional settings, will be understanding the potential transferrability of evidence (its public good characteristics) to avoid reinventing the wheel. In Europe, we finally are trying to do this through the EUnetHTA Joint Action. Let us try to avoid building in duplication from the beginning elsewhere in the world.
  • Successful implementation of UHC also will require creating incentives in health care systems to achieve better outcomes, and creating the tools and systems to measure performance.

In other words, diverse health systems have diverse needs for information, economic analysis and outcomes research.

ISPOR must lead the scientific developments necessary to respond to these needs. We must break out of the narrow perspective of focussing on very detailed analysis of new drugs. Undertaking such analyses is a key challenge for many health systems. And ISPOR members are very good at meeting this challenge in any setting. But issues around health policy, the architecture of the health system, and how high quality outcomes can be incentivised and monitored are also pressing – particularly, I would argue, in countries seeking to increase access to health care services.

To this end, we should remind ourselves that we already recognise this wider role for our methods and skills in ISPOR. Here are some definitions from the ISPOR Book of Terms:

  • Outcomes research is “the scientific discipline that evaluates the effect of health care interventions on patient related if not patient specific, clinical, humanistic and economic outcomes” (my emphasis)
  • A health care intervention is in turn “a program, policy, measure, or activity designed to have an impact on an illness or disease in an individual or a population” (my emphasis). This is not necessarily a single product
  • Health care technology (for HTA) consists of:

– Drugs, biologics, devices, procedures

Support systems, organisational, delivery and managerial systems (e.g. disease management programme, health care payment system) (my emphasis)

So I repeat again: diverse health systems have diverse needs for information, economic analysis and outcomes research. ISPOR can lead the scientific developments essential to responding to these needs. At stake is the ability of people around the world to gain access to universal health coverage — for the first time.

Of course, ISPOR already is global in its reach. An important part of ISPOR’s growing global footprint are the biennial conferences in Asia and in Latin America. I urge you to join me in Beijing in September for the next ISPOR conference, my first as ISPOR President, and remind you of the third ISPOR conference of 2014, in Amsterdam in November.

ISPOR’s publications are global and now include not only our flagship journal Value in Health, but also three regional issues of Value in Health – Asia, CEEWAA (Central and Eastern Europe, Western Asia, and Africa), and Latin America. The regional issues have moved to article-based electronic publishing with one full volume each year. The rising quality of these publications is reflected by (1) a projected 30% increase in the impact factor of Value in Health and (2) plans to get the regional issues included in Medline/PubMed.

Raising the global impact of ISPOR’s drive for good science is also reflected in the expanding webinar series and the current activities of the ISPOR Good Practice Task Forces.

I look forward to working with the new Incoming President Dan Malone, his newly elected colleagues on the board, and the continuing board members. Together, we will work to ensure that ISPOR continues to develop, with the support of a new executive director.

In closing, I emphasise once more that providing efficient and effective health care is truly a global challenge. ISPOR is a global organisation that exists to help meet this challenge. Diverse health systems face different challenges. ISPOR must anticipate and respond to this broad range of needs. We can do this.


Founded in 1995, ISPOR promotes the science of pharmacoeconomics (health economics) and outcomes research and facilitates the translation of this research into useful information for health care decision makers to increase the efficiency, effectiveness, and fairness of health care to improve health. It has more than 7300 members from 105 countries; the 71 ISPOR Regional Chapters have more than 6000 members, extending ISPOR’s outreach to over 13,300 members worldwide.

Orphan Drugs Policies: A Suitable Case for Treatment

OHE's Prof Adrian TowseAn editorial just published by OHE’s Adrian Towse and Michael Drummond of the University of York argues that current orphan drug policies are ‘not fit for purpose’ and discusses the issues that need to be clarified as the basis for policy revisions. The editorial is intended ‘not to provide complete solutions to all the policy problems, but rather to set out a roadmap whereby they can be resolved’. Four groups of issues are identified.

  1. Recent surveys appear to suggest that the general public would not necessarily allocate more resources to those with orphan diseases than those with common diseases. The authors suggest that those surveyed may have been influenced by how the questions were framed and that other methods of eliciting preferences should be tested. These include asking directly whether special funding for those suffering from orphan disease should exist and, if so, how much. Clarifying society’s preferences should be the first priority in working towards better public policy.
  1. How orphan drugs may be best assessed to determine pricing and reimbursement continues to present challenges. Towse and Drummond identify the primary challenges this has presented, and suggest potential responses. But they also raise an important, and controversial, issue:

If it is known in advance that most of these drugs will not be cost-effective based on standard criteria, why undertake the assessments in the first place, unless there is the possibility that better value for money could be obtained if the drugs were better targeted? It might be better to acknowledge at the outset that high-priced orphan drugs will not be reimbursed, thereby avoiding wasting resources on their assessment.  

  1. New approaches to treatment, including advances in targeting treatment to the individual patient, may produce the temptation for companies to make more ordinary diseases appear as ‘orphans’, according to Towse and Drummond. The problem of ensuring that incentives produce the intended consequences may require redefining ‘orphan disease’ or removing orphan status when a product achieves other, non-orphan, indications.
  1. ‘Probably the biggest concern about current policies for orphan drugs’, according to the authors, ‘is that the policies for stimulating research and providing reimbursement are at odds with one another, leading to inefficiencies if scarce resources are devoted to the research and development of drugs that are not going to be used’. These policies, they argue, must be ‘joined up’. This might include explicit statements of priority, signaling to drug developers which new products are most likely to receive reimbursement. Setting appropriate priorities, moreover, could be supported by product development partnerships that involve the public and charity sectors.

Towse and Drummond conclude that: ‘Without changes in the current policies, pharmaceutical companies will eventually cease responding to the incentives to develop orphan drugs because they will increasingly be uncertain whether the drugs, if developed, will be reimbursed’.

Open access: Drummond, M. and Towse, A., 2014. Orphan drugs policies: a suitable case for treatment. The European Journal of Health Economics. 15(4), pp.335-340.

For additional information, please contact Adrian Towse.


The Expanding Value Footprint of Oncology Treatments

The Expanding Value Footprint of Oncology DrugsA new OHE Consulting Report examines the importance and history of HTA evaluations for additional uses for cancer drugs after their initial approval.

The potential value of a new medicine is not likely to be fully known at the time of marketing approval. New uses can expand both the therapeutic and financial value of a particular medicine. In a new study, OHE Consulting seeks to describe and quantify such ‘value expansion’ for a cohort of cancer drugs.

The cohort of cancer drugs included are the ten approved by the EMA during 2003–2005[1]. This time period was chosen based on the assumption that cancer drugs on the market for eight years or more are likely to have been approved for additional indications. New indications, for example, may be for use in a different cancer, disease stage, treatment stage, treatment regimen, or patient population or subpopulation.

The decisions of three entities were included in the study: the Haute Autorité de Santé (HAS) in France, NICE in England and Wales, and Aetna, a private health insurance company in the US. These three were selected to suggest how assessment approaches might differ in interpreting value.

Seven of the ten drugs experienced value expansion after initial approval. For both NICE and HAS, a positive decision was more likely the greater the estimated gain in overall survival. HAS assessments of these ten cancer drugs resulted in reimbursement for 93% of the drugs, although this was at fairly low levels for more than 60%. In comparison, 63% of NICE appraisals resulted in a recommendation against use in the NHS. The statistics for Aetna are more difficult to interpret because the company may elect to reimburse for uses that have not been officially approved by the FDA and decisions affect only about 7% of the US population.

The study also tracks changes over time in price, volume and sales for the five medicines associated with the largest number of value expansions: Alimta, Avastin, Erbitux, Tarceva and Velcade. IMS data for 2004 through the end of Q3 2013 were used. Overall, prices, volume and sales were lower in the UK than in France and the US. Not surprisingly, additional licensed indications produced higher sales. However, for France and the UK, special access mechanisms muddy the water somewhat. France’s Temporary Authorisations for Use system in some cases has produced increases in use before an HAS decision; in the UK, sales for some cancer medicines increased after the 2010 introduction of the Cancer Drugs Fund even in the face of unfavourable NICE recommendations.

The value of a particular medicine, as this study illustrates well, may not be evident at the time of first approval and value can vary both over time and by indication. This may result in pricing and reimbursement decisions that fail to adequately reward important innovation and so discourage future innovation, to the detriment of society. Public policy options for addressing this challenge include, for example, pricing that varies by indication, and consideration of potential expanded use as part of the initial deliberations and decisions about pricing and reimbursement.

[1] Alimta, Avastin, Busilvex, Erbitux, Faslodex, Litak, Lysodren, Tarceva, Velcade, Zevalin

The full report is available for download from the OHE Consulting website.

Download: Rejón-Parrilla, J.C., Hernández-Villafuerte, K., Shah, K., Mestre-Ferrandiz, J., Garrison, L.   and Towse, A., 2014. The expanding value footprint of oncology treatments. Consulting report. London: Office of Health Economics.

For additional information about this study and OHE Consulting, please contact Jorge Mestre-Ferrandiz.



2014 Annual Lecture: Is Universal Health Care Coverage the Holy Grail?

AL_Danzon-for-2014-postJoin us on the evening of 9 June 2014 when OHE will welcome Professor Anne Mills of the London School of Hygiene and Tropical Medicine who will speak on Universal Health Care: the Holy Grail?

Health services available to the whole population free of charge, and providing the best health advice and treatment, was the foundation stone for the creation of the National Health Service. The health systems of most other high income countries similarly embody the ideal of universal health coverage. Yet low and lower middle income countries have recently been on the receiving end of global policies that have emphasised highly selective goals, in contrast to the initial broad themes of the Primary Health Care movement founded in Alma Ata in 1975 and pursued through WHO’s slogan ‘Health for All’. Recent policies have focussed on controlling specific diseases such as HIV and malaria and delivering specific interventions such as immunisation. In the last few years, universal health coverage has attracted greater attention. It has been the subject of World Health Assembly and UN General Assembly resolutions, and is being strongly advocated for inclusion in the post-2015 Millennium Development Goals.

This lecture will address the subject of universal health coverage in low and middle income countries. Professor Mills will discuss:
• What universal health coverage should encompass
• How it might be financed and organised
• What might be realistic goals in the short and medium term.

Professor Anne Mills CBE MA DHSA PhD FMedSci FRS is a world renowned expert in health economics, health care financing and policy in low and middle income countries.

She has a distinguished academic career at the London School of Hygiene and Tropical Medicine, where she is Vice Director of the School and Professor of Health Economics and Policy in the Department of Global Health and Development. She previously served as Director of the Health Economics and Financing Programme, which was supported by a variety of research grants from funders such as DFID, the Wellcome Trust, EU and WHO, and as the Head of the Faculty of Public Health and Policy. She has advised many multilateral, bilateral and government agencies; served on the WHO’s 2001 Commission on Macroeconomics and Health chaired by Jeffrey Sachs; and co-chaired one of the two Working Groups for the 2009 High Level Taskforce on Innovative International Finance for Health Systems, co-chaired by Prime Minister Gordon Brown.

In 2006 she was awarded a CBE for services to medicine and elected a Foreign Associate of the US Institute of Medicine. In 2009 she was elected Fellow of the UK Academy of Medical Sciences and received the Prince Mahidol Award in the field of medicine. She was President of the International Health Economics Association (iHEA) for 2012/13. She was elected a Fellow of the Royal Society in 2013.

Prior registration is required. Deadline for registration is 4 June, but seating is limited and these events fill quickly. Editor’s note: All spaces are now filled and registration is closed.

For information about recent OHE Annual Lectures, click here. To download copies of publications based on our Annual Lectures, click here. Publications from before 2004 are available on our archive site

Editor’s Note: The London School of Hygiene & Tropical Medicine is holding a health economics conference on 12 June 2014, bringing together an exciting programme of world-leading speakers on the past, present and future of the field, as practised in both high, and low-and middle-income, settings. For more information, click here.



Innovation in Oncology: Real Option Value and Path Dependence

Real Option Value and Path Dependence in Oncology InnovationBased on an OHE Lunchtime Seminar, this Seminar Briefing addresses a persistent issue: how to adequately reward innovation through the pricing of new medicines given the limitations of the information available at launch. As the author points out, oncology drugs in particular often follow the path of incremental innovation, proceeding in steps towards realising their full potential in treatment–and even cure.

The publication describes the importance of taking future value into consideration in the initial assessment to encourage and spur progress in innovation. The perspectives of the innovative company and the patient are discussed as well the implications for cost-effectiveness and comparative-effectiveness assessments.

Download: Cook, J.P., 2014. Real option value and path dependence in oncology innovation. Seminar Briefing. 14. London: Office of Health Economics.