The number of economic evaluations looking at integrated care has increased in recent years [1]. A definition that is often used for economic evaluations is that these studies include a comparison of two or more alternatives in terms of both their costs and consequences [2]. Economic evaluation studies thus relate the cost to the effects of integrated care. Often a comparison is made in which a ‘more coordinated and integrated form of care provision’ is compared to ‘care as usual’. In these economic evaluation studies, the costs are expressed in monetary terms and outcomes are usually expressed in non-monetary values, such as quality of care, quality of life, or quality of labour.
The costs of new care innovations, such as integrated care continue to be an important issue, due to global recession, ageing population and increasing demand for healthcare. In recent years, many of these economic evaluation studies started with an expose on the increasing public spending on care. The rise of care costs in several western countries was also one of the arguments for including economic aspects in research focussing on integrated care. In many countries, the rise of care costs is seen as a major problem to confront. As a result, many governments focus on potential cuts in new (and existing) integrated care intervention in order to reach a stabilisation of the growth of care expenditures. However, if the monetary benefits of new and existing (integrated) care interventions exceed the costs of these interventions, these spending cuts might be not sensible.
The issue is that economic evaluation studies in earlier decades have not been explicit about the monetary benefits of integrated care interventions, due to the fact that quality of care, quality of life, or quality of labour are difficult to express in monetary terms. In the Netherlands [3–6] as well as abroad [7], several projects are currently focussing again on the monetary value benefits of health and care interventions. To facilitate the process of including, next to the costs, also the monetary benefits of care, the Dutch Ministry of Health organised a conference on this subject [8]. The conference was aimed at presenting and discussing the direct and indirect monetary benefits of care.
The conference started off with a presentation by Professor Martin McKee of the London School of Hygiene and Tropical Medicine. Martin McKee was one of the driving forces behind the World Health Organisation conference on Health systems, health and wealth in Tallinn, Estonia in 2008. In his keynote lecture ‘Health is wealth’ [9], McKee aimed to disentangle the dynamic triangle between health systems, health and wealth. By doing this, he clarified the economic impact of health systems on health, economic growth, and social well-being. After McKee, several other speakers highlighted the benefits of care in and outside the healthcare sector.
Although sometimes under discussion, care has—next to hygienic measures, the environment and education—a direct influence on health. As a result, one of the benefits of care is that people live longer. Due to care, the quality of life of people increases as well, both in years of life lived anyway and in the life years gained, resulting in additional Quality Adjusted Life Years (QALYs). If we would materialise these life years gained as well as the increase in QALYs in monetary terms, insight could be given in the direct net monetary benefits of care. As an example, in the Netherlands these direct monetary benefits due to only additional health would lead to a return on investment of healthcare of an additional 11% [3].
Next to direct benefits resulting in people being healthier, investments in care also lead to an additional number of indirect monetary benefits. A recurrent subject in all studies is the positive influence of care, such as integrated care, on labour. This relation is established in several ways. Healthier people are more productive and ultimately this leads to a higher labour participation, a decrease in absenteeism, and a decrease in presenteeism. The societal impact is that healthier people have a higher productivity per hour and for the individuals, this will lead to a higher income. In addition, in many countries, as well as in the Netherlands, the care sector is an important business, providing employment and new innovations [2].
Adjacent to the influence of labour, a more healthy population will induce some other indirect benefits. Health has a positive influence on education and career opportunities. In addition, health does not only influence the person himself, but also their surroundings. Overall there is a strong relationship between the quality of life of the individual and that of their next of kin. The care provided by social environment of the care recipient plays a substantial role in the total care delivered as well. Although the methodologies between the studies were diverse and sometimes not well-documented, the overall conclusion is that if valued in monetary terms, the benefits of healthcare would exceed the costs of healthcare. On average, returns [2, 3] of about 30% were mentioned. The insight that care induces more monetary benefits than costs does not contain anything exceptionally new for experts in the field of health economics and integrated care.
As mentioned earlier, the issue is that the consequences of integrated care are often not valued in monetary terms. Subsequently, monetary savings are generally included in the costing side of the economic study and therefore not explicitly mentioned as benefits in an economic evaluation study. By being more explicit about the monetary benefits of integrated care intervention to society, the intrinsic value of care beyond health becomes more visible. If the direct and indirect benefits of care in general, but of integrated care especially, are counted and valued in monetary terms, it will highlight its economic importance. Although relatively few studies have been done to date [1], these renewed finding are challenging from a methodological point of view. It reveals that there is a need for well-designed methods to value consequences of integrated care into monetary terms. If we succeed in being more explicit about the monetary gains of integrated care, the costs of integrated care will be regarded more as investments instead of expenses.