Cost-effectiveness criteria are strictly consistent with a model of lifetime utility maximisation only if they account for effects on future related and unrelated medical expenditures.

.The magnitude of unrelated medical expenditures, consumption, and earnings may be large enough to alter the cost-effectiveness.

The inclusion or exclusion of future unrelated medical costs will not affect the ranking of cost effectiveness ratios, so that they can be neglected.

The inclusion of future unrelated medical costs will only add a constant figure to all cost-effectiveness ratios.

The US Panel made inconsistent recommendations by not including the future unrelated costs, which would seriously distort comparisons of healthcare programmes.

The inconsistency could be corrected by including the future unrelated costs, either medical or non-medical.

For primary prevention only a cost utility ratio that includes both the costs and effects of unrelated medical care meets the criterion of internal consistency and is related to a meaningful decision problem.

Only inclusion of all costs and effects of unrelated medical care in life-years gained can be considered both internally and externally consistent.

Including or excluding unrelated future medical costs may have important distributional consequences, especially for interventions that substantially increase length of life.

It is becoming increasingly possible to accurately estimate unrelated medical costs in life-years gained.

If the future costs were truly unrelated, it did not matter whether such costs were included or excluded, as long as the cost effectiveness threshold was properly adjusted.

The controversy for unrelated future costs in the literature is due to differences in modelling budget constraints.

Analyses that use a Conditional budget constraint imply that unrelated future costs need not be considered.

Analyses that use an Annuity budget constraint imply that future savings by a wide range of unrelated future costs need to be considered.

The paper goes on to argue that Conditional budget constraints are preferable.

Health maximisation and utility maximisation require accounting for the present value related future costs and ignoring unrelated future costs.

It is difficult to disentangle ‘related’ costs from ‘unrelated’ costs.

Economic models of intertemporal resource allocation to maximise utility under uncertainty imply that all future costs net of earnings should be included in cost-effectiveness analysis.

Lee’s paper did not resolve any controversy on the inclusion of future unrelated medical costs.

The practical problems in estimating are not unique nor sufficient reasons to ignore them and progress has been made for estimation.

Excluding future costs complicates comparisons of economic evaluations across disease areas and patient groups.

Pharmacoeconomic guidelines should be changed to include future unrelated medical costs.

Dialysis costs should be considered unrelated to a life-extending therapy.

Exclusion future unrelated costs is entirely consistent with current pharmacoeconomic guidelines and clinical practice, providing cost-effectiveness ratios that are comparable to other products.

All relevant costs for the perspective selected should probably be included in economic evaluations including related or unrelated, direct or indirect future costs.

There is no rationale for excluding unrelated future costs, while at the same time including unrelated future benefits in an economic evaluation.

Including the costs of future healthcare decisions may make a material difference to results.

Including ‘related’ but excluding ‘unrelated’ future costs requires analysts to make judgements about whether particular costs are related or unrelated.

Practical relevance of including the costs of future unrelated medical care is illustrated using the example of transcatheter aortic valve implantation.

The optimal decisions within a healthcare perspective require future unrelated medical costs to be included.

Consistency requires that the benefits of unrelated medical care should also be excluded if costs thereof are excluded.

Excluding the costs and benefits in some circumstances may erroneously result in labelling a cost-effective intervention as cost-ineffective.

Inclusion: van Baal et al thought more health would result from including all future care costs in decisions to approve interventions.

Exclusion: Sarah Davis worried that always including unrelated costs might lead to unfair distribution of care, including among people with incurable illness.

A consensus was not reached on the inclusion of healthcare costs unrelated to the intervention (round 1, 53% agreement; round 2, 50% agreement).

Panellists in favour of inclusion argued that unrelated future healthcare costs should theoretically be included if an intervention prolongs life and if important differences in future costs between interventions are expected.

Others argued against inclusion on the basis that the calculations are difficult as many assumptions are made.

The steering committee recommended the inclusion of related and unrelated future healthcare costs if the intervention is expected to result in an extension of life, because it represent a true use of resources.

Economic evaluation is rarely to identify and quantify the impact of ill health but informs decisions about whether a specific technology should be funded from fixed budget. Therefore, consideration of the scope of costs and benefits for inclusion has a normative component that derives from the policy objectives.

The expansion of the scope of costs and benefits beyond direct costs and health accruing to the treated individuals may lead to unintended effects on the distribution.

There is value in the inclusion of future medical costs in economic evaluation to support decision-makers’ considerations relating to future healthcare budgets.

This study demonstrated the practicability of including future medical costs in an economic evaluation in cancer patients.

There is considerable heterogeneity in the ICERs across different cancer types and the types of future costs included do not impact all cancers consistently.

To allow optimal decisions, both from a healthcare and societal perspective, including the additional related and unrelated medical costs in economic evaluations is required.

Knowledge on how to estimate future (unrelated) medical costs has improved, also allowing inclusion in practice.

Inclusion of these costs would presumably benefit most from lowering the practical difficulties and the burden on the analyst of including these costs in a cost-effectiveness analysis, as well as guidelines prescribing or at least encouraging inclusion rather than prescribing exclusion.

Including the costs of unrelated medical care makes sense as these costs also contribute to the health gains which are implicitly included in practice.

Future unrelated costs are real and will affect the budget left for other care.

Ignoring future unrelated medical costs results in an underestimate of QALY losses of unidentified patients in the future.

For some patient groups, including future unrelated medical costs may imply a huge increase in the ICER for life-prolonging technologies and thereby trigger difficult ethical debates.

The practical difficulties around the estimation of future costs can be overcome.

The case studies demonstrate that including future costs, even just unrelated medical costs, can have a substantial effect on the ICER, which could affect decision-makers’ choices.

The results show that including future unrelated medical costs is feasible and standardisable.

Empirical examples show that this inclusion leads to an increase in the ICER of between 7% and 13%.