Why Health Economics Reports Need a Global Makeover

The $4 Trillion Blind Spot

In 2020, a team of researchers in Canada and the UK did something unusual. They gathered a small group of patients with chronic conditions, sat them down at a table, and asked: “What does a good outcome actually look like to you?”

The answers were not what the economists expected. Patients talked about being able to walk their dog without stopping to catch their breath. They talked about sleeping through the night without pain. They talked about the dignity of not having to ask their adult children for help bathing.

These are things that almost never appear in health economics reports. When a drug company or a government agency decides whether a new treatment is “worth it,” they measure costs. They measure hospital readmissions. They measure survival rates. But they rarely measure whether a patient can walk their dog.

This mismatch is not a minor oversight. It is a structural flaw in how the world decides which treatments to fund, which drugs to approve, and which lives to prioritize. And after nearly a decade of watching this problem fester, a coalition of global health economists has released a new set of reporting standards designed to fix it. The 2022 update to the Consolidated Health Economic Evaluation Reporting Standards, or CHEERS, represents the most significant attempt yet to drag health economics into the messy, subjective reality of what patients actually experience (Husereau et al., 2022).

What Health Economics Gets Wrong About Human Life

Health economic evaluation sounds dry, but it governs something deeply personal: whether you or someone you love gets access to a treatment. Every country with a public health system, from the UK’s National Institute for Health and Care Excellence to Australia’s Pharmaceutical Benefits Advisory Committee, uses these evaluations to decide what to pay for.

The basic logic is straightforward. You compare two or more treatments. You measure their costs. You measure their outcomes. You calculate which one gives you the most health per dollar spent.

The problem is in the measurement.

For decades, the gold standard for measuring outcomes has been something called the Quality Adjusted Life Year, or QALY. It combines how long a treatment extends your life with how “good” those extra years are, on a scale from 0 (dead) to 1 (perfect health). A year of perfect health is worth 1 QALY. A year in a coma is worth 0. A year with moderate pain might be worth 0.6.

The QALY is elegant, mathematical, and deeply flawed. It was developed in the 1970s based on surveys of people who were mostly healthy, mostly white, and mostly not poor. The values assigned to different health states were determined by asking people to make hypothetical trade offs: “Would you rather live 10 years with blindness or 5 years with perfect health?” The answers produced a universal scale that could be applied to anyone.

But human beings do not experience health universally. A person who has lived with chronic pain for twenty years may rate their quality of life very differently than a healthy person imagining what that pain would be like. A parent of a child with a disability may value outcomes that the standard QALY simply does not capture.

The CHEERS 2022 authors do not call out the QALY by name, but they build a framework that implicitly challenges its dominance. The new standards require researchers to report “the perspective of the analysis,” meaning they must explicitly state whose values are being used to measure outcomes. Is it the patient’s perspective? The clinician’s? The taxpayer’s? The difference matters enormously.

The 28 Questions That Could Change Everything

The original CHEERS statement from 2013 was a 24 item checklist. It was a good start, but it treated health economics as a technical exercise: did you model the costs correctly? Did you report the discount rate? Did you disclose conflicts of interest?

The 2022 version expands to 28 items and fundamentally shifts the focus. For the first time, researchers are required to report on stakeholder involvement, specifically “how patients, service recipients, or the public were involved in the design, conduct, or interpretation of the evaluation” (Husereau et al., 2022).

This is not a footnote. It is a recognition that the people who live with diseases have expertise that economists do not.

How the Checklist Works

The CHEERS 2022 checklist is organized into seven sections, each targeting a different phase of reporting:

• ▸Title and abstract: Must make clear that this is a health economic evaluation, not a clinical trial
• ▸Introduction: Must state the “health problem” being addressed, including its “burden on individuals and populations”
• ▸Methods: The longest section, covering everything from the study perspective to the time horizon to the measurement of outcomes
• ▸Results: Must report both absolute and relative differences between interventions
• ▸Discussion: Must address “limitations, generalizability, and current knowledge”
• ▸Other: Funding, conflicts, and now “stakeholder involvement”

The stakeholder involvement item is Item 8 in the methods section. It requires researchers to describe “approaches used to engage stakeholders in the design, conduct, or interpretation of the evaluation” (Husereau et al., 2022). If no stakeholders were involved, researchers must justify why.

This is a quiet revolution. For decades, health economic models were built by PhDs in offices, using assumptions about what patients valued. The CHEERS 2022 authors are saying: go ask them.

The Hidden Politics of Cost Effectiveness

One of the most revealing aspects of the CHEERS 2022 update is what it says about perspective. Item 5 requires researchers to report “the perspective of the study relative to the costs and outcomes being evaluated” (Husereau et al., 2022).

This sounds technical, but it is deeply political. Consider a new drug for a rare genetic disorder. From the perspective of a hospital budget, the drug looks expensive: it costs $500,000 per patient per year. From the perspective of a health system, it might look different: the drug prevents hospitalizations that would have cost $1 million over a patient’s lifetime. From the perspective of a patient, it might look entirely different again: the drug allows them to hold a job, care for their children, and avoid bankruptcy from medical bills.

Most health economic evaluations choose one perspective and stick with it, often the health system perspective. The CHEERS 2022 authors are pushing for transparency about which choice was made and why.

The Equity Problem

The original CHEERS statement was silent on equity. The 2022 version introduces a new item, Item 14, which requires researchers to describe “any distributional considerations that may affect the results” (Husereau et al., 2022).

This matters because health economics has an equity blind spot. Standard cost effectiveness analysis assumes that a QALY is a QALY, whether it goes to a wealthy CEO or a homeless teenager. But societies do not actually make decisions that way. Most countries explicitly or implicitly prioritize treatments for the sickest patients, even if those treatments are less cost effective than preventive care for healthier people.

The CHEERS 2022 authors do not tell researchers how to handle equity. They just insist that researchers acknowledge it. That alone is a step forward.

What the Paper Actually Found

The CHEERS 2022 paper is not a study in the traditional sense. It is a consensus statement, developed by a task force of 23 experts from 11 countries, representing academia, government, and industry. The authors conducted a systematic review of existing reporting standards, surveyed health economists about gaps in the original CHEERS, and held multiple rounds of Delphi voting to reach agreement on the new items.

The result is a checklist that the authors believe “can be more easily applied to all types of health economic evaluation” and that reflects “new methods and developments in the field, and the increased role of stakeholder involvement including patients and the public” (Husereau et al., 2022).

But the real finding is not in the checklist itself. It is in what the checklist reveals about the state of the field.

The Three Most Important Changes

• ▸Broadening the definition of intervention: The original CHEERS focused on pharmaceuticals and medical devices. The 2022 version applies to “any form of intervention intended to improve the health of individuals or the population, whether simple or complex, and without regard to context (such as healthcare, public health, education, and social care)” (Husereau et al., 2022). This means a housing program for homeless people with diabetes can now be evaluated using the same standards as a new insulin pump.

• ▸Requiring justification for modeling choices: Item 13 asks researchers to report “the time horizon over which costs and consequences are being evaluated and why it is appropriate” (Husereau et al., 2022). This sounds basic, but many evaluations pick a time horizon based on convenience rather than clinical reality. A one year horizon might miss long term side effects. A lifetime horizon might require heroic assumptions about future costs.

• ▸Adding a section on the impact of uncertainty: Item 20 requires researchers to describe “the effect of uncertainty on the results” (Husereau et al., 2022). This is a subtle but important shift. In the past, researchers could report a single cost effectiveness ratio and call it a day. Now they must show how the answer changes if their assumptions are wrong.

What the Research Does Not Prove

The CHEERS 2022 paper is a reporting standard, not a scientific finding. It does not prove that stakeholder involvement leads to better health outcomes. It does not prove that current health economic evaluations are wrong. It does not even prove that the new checklist will improve reporting quality.

What it does is establish a norm. The authors are saying: if you want to publish a health economic evaluation in a reputable journal, here is what you need to report. The hope is that this norm will change behavior over time.

The open question is whether it will work. Reporting standards have a mixed track record. The CONSORT statement for clinical trials improved reporting, but did not eliminate selective reporting of outcomes. The PRISMA statement for systematic reviews made meta analyses more transparent, but did not stop researchers from cherry picking studies.

The CHEERS authors are aware of this. They note that the checklist is “primarily intended for researchers reporting economic evaluations for peer reviewed journals and the peer reviewers and editors assessing them for publication” (Husereau et al., 2022). But they also acknowledge that “familiarity with reporting requirements will be useful for analysts when planning studies.”

In other words, the checklist is a tool, not a cure. It will only work if journals enforce it, if reviewers demand it, and if researchers internalize it.

The Global Makeover Begins

The title of this article promises a global makeover, and the CHEERS 2022 authors deliver something close to that. But a makeover is not the same as a transformation.

The fundamental tension in health economics remains: how do you quantify the value of a human life? The CHEERS 2022 checklist does not answer that question. It just forces researchers to be more honest about how they are answering it.

That honesty is long overdue. Every day, health systems around the world make decisions that affect millions of lives based on economic models that patients never see and rarely understand. The CHEERS 2022 standards are a small step toward making those models more transparent, more inclusive, and more accountable to the people they are supposed to serve.

The patients who just want to walk their dog will probably never read the CHEERS 2022 checklist. But if the standards work as intended, the next time an economist evaluates a treatment that could help them, someone will ask: “What does a good outcome look like to you?”

What This Actually Means

• ▸Health economic evaluations should include patient perspectives, not just clinical endpoints. If you are on a health technology assessment committee, demand evidence of stakeholder involvement in every submission you review.
• ▸The choice of perspective in an economic evaluation is a value judgment, not a technical detail. When reading a cost effectiveness study, always ask: whose costs are being counted, and whose outcomes are being measured?
• ▸Equity considerations matter, even if they complicate the math. The CHEERS 2022 authors are saying that a QALY is not a QALY is not a QALY. Treating everyone the same in a model can perpetuate real world inequalities.
• ▸Reporting standards are only as good as their enforcement. Journal editors and peer reviewers are the gatekeepers. If they do not require authors to complete the CHEERS 2022 checklist, the standards will remain aspirational.
• ▸The definition of “intervention” is expanding. Health economists are now evaluating housing programs, food assistance, and social services. If your organization works on social determinants of health, you should be familiar with these standards. They apply to you.