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Abstract
There has been substantial debate on the need for decreasing discounting for monetary and health gains in economic evaluations. Next to the discussion on differential discounting, a way to identify the need for such discounting strategies is through eliciting the time preferences for monetary and health outcomes. In this article, the authors investigate the perceived time preference for money and health gains through a pilot survey on Dutch university students using methods on functional forms previously suggested. Formal objectives of the study were to review such existing methods and to pilot them on a convenience sample using a questionnaire designed for this specific purpose. Indeed, a negative relation between the time of delay and the variance of the discounting rate for all models was observed. This study was intended as a pilot for a large-scale population-based investigation using the findings from this pilot on wording of the questionnaire, interpretation, scope and analytic framework.
Financial & competing interests disclosure
This study was financed by grants from GSK Biologicals Wavre (Belgium) and Zon/Mw. Both grants were unrestricted. M Postma received grants, honoraria and travel stipends from various pharmaceutical companies, inclusive of those potentially interested in the subject matter of this paper. T Westra is currently employed with GSK Zeist (The Netherlands); however, this paper was developed during his affiliate with University Medical Center Groningen (UMCG)/University of Groningen (Netherlands). The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.
No writing assistance was utilized in the production of this manuscript.
Appendix
Questionnaire
Part A
This part of the questionnaire is on your personal situation, work and income.
A1. What is your gender?
▪ Female
▪ Male
A2. What is your age?
▪ ..... years
A3. What is your highest level of education? (High school and college levels are in Dutch terminology)
▪ Primary school
▪ High school: “Huishoudschool, LTS, LEAO, VMBO, etc.”
▪ High school: “VMBO theoretische leerweg, MAVO, (M) ULO, MMS, three years of HBS”
▪ High school: “HAVO, VWO, HBS”
▪ College: “MTS, MEAO, etc.”
▪ University/College: Degree: BA, BS, Ing.
▪ University/College: Degree MA, MS, Drs, Ir, PhD
A4. What is your current marital status?
▪ Married
▪ Single, never married
▪ Divorced
▪ Widowed
▪ Cohabiting
▪ Don’t want to tell/Other
A5. Do you have children?
▪ No
▪ Yes
If yes:
- How many children do you have?
- What is the age of the youngest child? …. years
A6. What is your occupation?
▪ Pay rolled/Wage labour
▪ Self employed
▪ Homemaker/Housekeeping
▪ Retired
▪ Unemployed/Looking for a job
▪ Unable to work due to disability
▪ Student
A7. What’s your nationality?
▪ Dutch
▪ Turkish
▪ Surinamese
▪ Moroccan
▪ Antillian / Aruban
▪ Other, namely:……………………..
A8. What is your religion?
▪ Protestant (“Nederlands Hervormd/Gereformeerd”)
▪ Roman Catholic
▪ Islamic
▪ Jewish
▪ Hindu
▪ None
▪ Other, namely: ……………………
A9. What is your monthly net household income?
▪ less than 999 Euros per month
▪ between 1000 and 1499 Euros per month
▪ between 1500 and 1999 Euros per month
▪ between 2000 and 2499 Euros per month
▪ between 2500 and 2999 Euros per month
▪ between 3000 and 3499 Euros per month
▪ between 3500 and 3999 Euros per month
▪ between 4000 and 4499 Euros per month
▪ between 4500 and 4999 Euros per month
▪ between 5000 and 5999 Euros per month
▪ between 6000 and 6999 Euros per month
▪ between 7000 and 7999 Euros per month
▪ 8000 Euros per month or more
Part B
The following questions are about your own state of health today. Please indicate, which statements most accurately describe your own health today.
B1. Mobility
1. I don’t have trouble walking
2. I have some trouble walking
3. I am confined to bed
B2. Self-Care
1. I don’t have problems with washing or dressing myself
2. I have some problems with washing or dressing myself
3. I am unable to wash or dress myself
B3. Usual activities (e.g., work, study, household, family or leisure activities)
1. I have no problems with performing my usual activities
2. I have some problems with performing my usual activities
3. I am unable to perform my usual activities
B4. Pain and/or Discomforts
1. I don’t have any pain or discomforts
2. I have moderate pain and/or discomforts
3. I have extreme pain and/or discomforts
B5. Mood
1. I am not anxious or depressed
2. I am moderately anxious and/or depressed
3. I am extremely anxious and/or depressed
B6.
We would like you to rate the current state of your health on the scale below.
The best state you can imagine is marked 100 and the worst state you can imagine is marked 0.
Part C
C.1 Money
The following four questions are on your preferences for the society as a whole saving or earning amounts of money. What would you choose from such a societal perspective? Imagine you are a policy-maker deciding on health care budgets. The decision does not directly affect yourself; the population for which you decide remains stable, i.e., does not grow or decline.
In all questions, suppose that the value of money does not change over time (so no inflation occurs).
Question 1
a. If you could choose between €30.000 one-year from now or €30.000 five years from now, what would you choose?
A: €30.000 one-year from now
B: €30.000 five years from now
C: Both options are equal to me.
(Exact numericals in following questions are determined by the software based on the previous answer, numbers shown below are examples)
b. And if you could choose between €30.000 in one-year from now or €75.000 in five years from now, what would you choose?
A: €30.000 in one-year from now
B: €75.000 in five years from now
C: Both options are equal to me.
c. And if you could choose between €30.000 one-year from now or €55.000 five years from now, what would you choose?
A: €30.000 one-year from now
B: €55.000 five years from now
C: Both options are equal to me.
d. And if you could choose between €30.000 one-year from now or €40.000 five years from now, what would you choose?
A: €30.000 one-year from now
B: €40.000 five years from now
C: Both options are equal to me.
e. And if you could choose between €30.000 one-year from now or €35.000 five years from now, what would you choose?
A: €30.000 one-year from now
B: €35.000 five years from now
C: Both options are equal to me.
f. According to your answers, an amount of €30.000 one-year from now has an equal value to you as an amount of somewhere between €35.000 and €40.000 five years from now. (Range is being determined by the software from above answers, range shown is example)
We would like you to indicate on the scale below, the exact amount between €35.000 and €40.000, which, if saved or received five years from now, would have the exact same value to you as saving/receiving one-year from now.
Question 2
a. If you could choose between €30.000 one-year from now or €30.000 10 years from now, what would you choose?
A: €30.000 one-year from now
B: €30.000 10 years from now
C: Both options are equal to me.
(Exact numericals in following questions are determined by the software based on the previous answer, numbers shown below are examples)
b. And if you could choose between €30.000 one-year from now or €85.000 10 years from now, what would you choose?
A: €30.000 one-year from now
B: €85.000 10 years from now
C: Both options are equal to me.
c. And if you could choose between €30.000 one-year from now or €65.000 10 years from now, what would you choose?
A: €30.000 one-year from now
B: €65.000 10 years from now
C: Both options are equal to me.
d. And if you could choose between €30.000 one-year from now or €45.000 10 years from now, what would you choose?
A: €30.000 one-year from now
B: €45.000 10 years from now
C: Both options are equal to me.
e. And if you could choose between €30.000 one-year from now or €38.000 10 years from now, what would you choose?
A: €30.000 one-year from now
B: €38.000 10 years from now
C: Both options are equal to me.
f. According to your answers, an amount of €30.000 one-year from now has an equal value to you as an amount of somewhere between €38.000 and €45.000 10 years from now. (Range is determined by the software from above answers, range shown is example)
We would like you to indicate on the scale below, the exact amount between €38.000 and €45.000, which, if saved or received 10 years from now, would have the exact same value to you as saving/receiving €30,000 one-year from now.
Question 3
a. If you could choose between €30.000 one-year from now or €30.000 20 years from now, what would you choose?
A: €30.000 one-year from now
B: €30.000 20 years from now
C: Both options are equal to me.
(Exact numericals in following questions are determined by the software based on the previous answer, numbers shown below are examples)
b. And if you could choose between €30.000 one-year from now or €125.000 20 years from now, what would you choose?
A: €30.000 one-year from now
B: €125.000 20 years from now
C: Both options are equal to me.
c. And if you could choose between €30.000 one-year from now or €85.000 20 years from now, what would you choose?
A: €30.000 one-year from now
B: €85.000 20 years from now
C: Both options are equal to me.
d. And if you could choose between €30.000 one-year from now or €65.000 20 years from now, what would you choose?
A: €30.000 one-year from now
B: €65.000 20 years from now
C: Both options are equal to me.
e. And if you could choose between €30.000 one-year from now or €50.000 20 years from now, what would you choose?
A: €30.000 one-year from now
B: €50.000 20 years from now
C: Both options are equal to me.
f. According to your answers, an amount of €30.000 one-year from now has an equal value to you as an amount of somewhere between €50.000 and €65.000 20 years from now. (Range is determined by the software based on above answers, range shown is an example)
We would like you to indicate on the scale below, the exact amount between €50.000 and €65.000, which, if saved or received 20 years from now, would have the exact same value to you as saving/receiving €30,000 one-year from now.
Question 4
a. If you could choose between €30.000 one-year from now or €30.000 40 years from now, what would you choose?
A: €30.000 one-year from now
B: €30.000 40 years from now
C: Both options are equal to me.
(Exact numericals in following questions are determined by the software based on the previous answers, numbers shown below are examples)
b. And if you could choose between €30.000 one-year from now or €300.000 40 years from now, what would you choose?
A: €30.000 one-year from now
B: €300.000 40 years from now
C: Both options are equal to me.
c. And if you could choose between €30.000 one-year from now or €250.000 40 years from now, what would you choose?
A: €30.000 one year from now
B: €250.000 40 years from now
C: Both options are equal to me.
d. And if you could choose between €30.000 one year from now or €200.000 40 years from now, what would you choose?
A: €30.000 one-year from now
B: €200.000 40 years from now
C: Both options are equal to me.
e. And if you could choose between €30.000 one-year from now or €150.000 40years from now, what would you choose?
A: €30.000 one-year from now
B: €150.000 40 years from now
C: Both options are equal to me.
f. According to your answers, an amount of €30.000 one-year from now has an equal value to you as an amount of somewhere between €150.000 and €200.000 40-years from now.
(Range is determined by the software based on above answers, range shown is example)
We would like you to indicate on the scale below, the exact amount between €150.000 and €200.000, which, if saved or received 40 years from now, would have the exact same value to you as saving/receiving €30,000 one-year from now.
C.2 Health
The following four questions are on health and your preference, again from a societal perspective rather than your own private one. Again as a policy maker in health care, you have to decide between a treatment next year of a population getting disease without that treatment or treatment of a similar population beyond next year (exact timing indicated in the question). Populations are exact similar in terms of age, gender, and other relevant characteristics for the disease concerned; the decision does not affect yourself, only the respective populations.
First, we would like you to pay attention to the following states of health, just to get an idea of how it works. You don’t have to choose yet.
1. Decreasing mobility due to walking problems gives a 15 points loss.
2. Severe anxiety/depression gives a 32 points loss.
3. Severe pain and at the same time being unable to perform usual activities gives a 56 points loss.
Question 1
a. At question B6 you indicated your own health with … points (score is shown).
Assume the average health score of the group in society you are responsible for is 85 points (score is shown).
Suppose that due to the disease concerned, the group in society you are responsible for would lose 30 points on average (again score is shown).
Assume, this lower health rate would last for a year, after that society’s average health would return back to its previous score (85).
Suppose this temporal loss of health would occur one year or five years from now, what would you prefer?
Attention: The loss of health occurs all of a sudden, no one knows beforehand when or that it will occur.
A: A loss of 30 points one-year from now
B: A loss of 30 points five years from now
C: Both options are equal to me.
(Exact numericals in following questions are determined by the software based on the previous answers, numbers shown below are examples)
b. Suppose the decrease in health would be larger when it occurs later, so smaller when it occurs earlier, what would your choice be in that case?
A: A loss of 25 points one-year from now
B: A loss of 30 points five years from now
C: Both options are equal to me.
c. Suppose the decrease in health would be larger when it occurs later, so smaller when it occurs earlier, what would your choice be in that case?
A: A loss of 15 points one-year from now
B: A loss of 30 points five years from now
C: Both options are equal to me.
d. According to your answers, losing 30 points five years from now has an equal value to you as losing an amount of points of somewhere between 15 and 25 points in one-year from now.
(Range is determined by the computer based on above answers, range shown is example)
We would like you to indicate on the scale below, the exact number of points between 15 and 25, which, if lost one year from now, would have the exact same value to you as losing 30 points five years from now, from your societal perspective taken.
Question 2 (has the same introduction as Question 1)
Suppose this temporal loss of health would occur one year, or ten years from now, what would you prefer?
Attention: The loss of health occurs all of a sudden, no one knows beforehand when or that it will occur
A: A loss of 30 points one-year from now
B: A loss of 30 points 10 years from now
C: Both options are equal to me.
(Exact numericals in following questions are determined by the software based on the previous answers, numbers shown below are examples)
b. Suppose the decrease in health would be larger when it occurs later thus smaller when it occurs earlier. What would your choice be in that case?
A: A loss of 25 points one-year from now
B: A loss of 30 points 10 years from now
C: Both options are equal to me.
c. Suppose the decrease in health would be larger when it occurs later thus smaller when it occurs earlier. What would your choice be in that case?
A: A loss of 15 points in one-year from now
B: A loss of 30 points in 10 years from now
C: Both options are equal to me.
d. According to your answers, losing 30 points 10 years from now has an equal value to you as losing an amount of points of somewhere between 15 and 25 points in one-year from now.
(Range is determined by the computer based on above answers, range shown is example)
We would like you to indicate on the scale below, the exact number of points between 15 and 25, which, if lost one year from now, would have the exact same value to you as losing 30 points 10 years from now, from your societal perspective taken.
Question 3 (has same introduction again)
Suppose this temporal loss of health would occur one-year, or 20 years from now, what would you prefer?
Attention: The loss of health occurs all of a sudden, no one knows beforehand when it will occur.
A: A loss of 30 points one-year from now
B: A loss of 30 points 20 years from now
C: Both options are equal to me.
(Exact numericals in following questions are determined by the software based on the previous answers, numbers shown below are examples)
b. Suppose the decrease in health would be larger when it occurs later thus smaller when it occurs earlier. What would your choice be in that case?
A: A loss of 25 points one-year from now
B: A loss of 30 points 20 years from now
C: Both options are equal to me.
c. Suppose the decrease in health would be larger when it occurs later thus smaller when it occurs earlier. What would your choice be in that case?
A: A loss of 10 points one-year from now
B: A loss of 30 points 20 years from now
C: Both options are equal to me.
d. According to your answers, losing 30 points 20 years from now has an equal value to you as losing an amount of points of somewhere between 10 and 25 points in one-year from now.
(Range is determined by the computer based on above answers, range shown is example)
We would like you to indicate on the scale below, the exact number of points between 10 and 25, which, if lost one-year from now, would have the exact same value to you as losing 30 points 20 years from now, from your societal perspective taken.
Question 4 (has same introduction again)
a. Suppose this temporal loss of health would occur one-year or 40 years from now, what would you prefer?
Attention: The loss of health occurs all of a sudden, no one knows beforehand when it will occur.
A: A loss of 30 points one-year from now
B: A loss of 30 points 40 years from now
C: Both options are equal to me.
(Exact numericals in following questions are determined by the software based on the previous answers, numbers shown below are examples)
b. Suppose the decrease in health would be larger when it occurs later thus smaller when it occurs earlier. What would your choice be in that case?
A: A loss of 20 points one-year from now
B: A loss of 30 points 40 years from now
C: Both options are equal to me.
c. Suppose the decrease in health would be larger when it occurs later thus smaller when it occurs earlier. What would your choice be in that case?
A: A loss of 5 points one-year from now
B: A loss of 30 points 40 years from now
C: Both options are equal to me.
d. According to your answers, losing 30 points 40 years from now has an equal value to you as losing an amount of points of somewhere between 5 and 20 points in one-year from now.
(Range is determined by the computer based on above answers, range shown is example)
We would like you to indicate on the scale below, the exact number of points between 5 and 20, which, if lost one-year from now, would have the exact same value to you as losing 30 points 40 years from now, from your societal perspective taken.
C.3 Life years
The following four questions are on your preferences for life years gained from a societal perspective. As a policy maker in the health-care area, you are asked to choose between two treatments prolonging life of the population you are responsible for. Treatment options differ in their timing of prolonging life in the population; i.e., next year versus farther into the future. Both treatments are equally costly and are paid for in the present/now. What would you choose? The decision does not affect yourself.
Question 1
a. If you could choose between one extra life-year gained one-year from now or one extra life-year gained five years from now, what would you choose?
A: One extra life-year gained one-year from now
B: One extra life-year gained five years from now
C: Both options are equal to me.
(Exact numericals in following questions are determined by the software based on the previous answer, numbers shown below are examples)
b. And if you could choose between one extra life-year gained one-year from now or two extra life years gained five years from now, what would you choose?
A: One extra life-year gained one-year from now
B: Two extra life years gained five years from now
C: Both options are equal to me.
c. And if you could choose between one extra life-year gained one-year from now or three extra life years gained five years from now, what would you choose?
A: One extra life-year gained one-year from now
B: Three extra life years gained five years from now
C: Both options are equal to me.
d. And if you could choose between one extra life-year gained one-year from now or four extra life years gained five years from now, what would you choose?
A: One extra life-year gained one-year from now
B:Four extra life years gained five years from now
C: Both options are equal to me.
e. And if you could choose between one extra life-year gained one year from now or five extra life years gained five years from now, what would you choose?
A: One extra life-year gained one-year from now
B: Five extra life years gained five years from now
C: Both options are equal to me.
f. According to your answers, gaining one life-year one-year from now has an equal value to gaining one to five life years five years from now. (Range is being determined by the software from above answers, range shown is example)
We would like you to indicate on the scale below, the exact amount of life years gained between one life-year and five life years, which, if received five years from now, would have the exact same value to you as a gain of one life-year one-year from now.
Question 2 (has same introduction)
a. If you could choose between one extra life-year gained one year from now or one extra life-year gained 10 years from now, what would you choose?
A: One extra life-year gained one-year from now
B: One extra life-year gained 10 years from now
C: Both options are equal to me.
(Exact numericals in following questions are determined by the software based on the previous answer, numbers shown below are examples)
b. And if you could choose between one extra life-year gained one-year from now or two extra life years gained 10 years from now, what would you choose?
A: One extra life-year gained one-year from now
B: Two extra life years gained 10 years from now
C: Both options are equal to me.
c. And if you could choose between one extra life-year gained one-year from now or three extra life years gained 10 years from now, what would you choose?
A: One extra life-year gained one-year from now
B: Three extra life years gained 10 years from now
C: Both options are equal to me.
d. And if you could choose between one extra life-year gained one-year from now or four extra life years gained 10 years from now, what would you choose?
A: One extra life-year gained one-year from now
B: Four extra life years gained 10 years from now
C: Both options are equal to me.
e. And if you could choose between one extra life-year gained one-year from now or five extra life years gained 10 years from now, what would you choose?
A: One extra life-year gained one-year from now
B: Five extra life years gained 10 years from now
C: Both options are equal to me.
f. According to your answers, gaining one life-year one-year from now has an equal value to gaining one to five life years 10 years from now. (Range is being determined by the software from above answers, range shown is example)
We would like you to indicate on the scale below, the exact amount of life years gained between one life-year and five life years, which, if received 10 years from now, would have the exact same value to you as a gain of one life-year one-year from now.
Question 3 (same introduction again)
a. If you could choose between one extra life-year gained one-year from now or one extra life-year gained 20 years from now, what would you choose?
A: One extra life-year gained one-year from now
B: One extra life-year gained 20 years from now
C: Both options are equal to me.
(Exact numericals in following questions are determined by the software based on the previous answer, numbers shown below are examples)
b. And if you could choose between one extra life-year gained one-year from now or two extra life years gained 20 years from now, what would you choose?
A: One extra life-year gained one-year from now
B: Two extra life years gained 20 years from now
C: Both options are equal to me.
c. And if you could choose between one extra life-year gained one-year from now or three extra life years gained 20 years from now, what would you choose?
A: One extra life-year gained one-year from now
B: Three extra life years gained 20 years from now
C: Both options are equal to me.
d. And if you could choose between one extra life-year gained one-year from now or four extra life years gained 20 years from now, what would you choose?
A: One extra life-year gained one-year from now
B: Four extra life years gained 20 years from now
C: Both options are equal to me.
e. And if you could choose between one extra life-year gained one-year from now or five extra life years gained 20 years from now, what would you choose?
A: One extra life-year gained one-year from now
B: Five extra life years gained 20 years from now
C: Both options are equal to me.
f. According to your answers, gaining one life–year one- year from now has an equal value to gaining one to five life years 20 years from now. (Range is being determined by the software from above answers, range shown is example)
We would like you to indicate on the scale below, the exact amount of life years gained between one life-year and five life years, which, if received 20 years from now, would have the exact same value to you as a gain of one life-year one-year from now.
Question 4 (same introduction again)
a. If you could choose between one extra life-year gained one-year from now or one extra life-year gained 40 years from now, what would you choose?
A: One extra life-year gained one-year from now
B: One extra life-year gained 40 years from now
C: Both options are equal to me.
(Exact numericals in following questions are determined by the software based on the previous answer, numbers shown below are examples)
b. And if you could choose between one extra life-year gained one-year from now or two extra life years gained 40 years from now, what would you choose?
A: One extra life-year gained one-year from now
B: Two extra life years gained 40 years from now
C: Both options are equal to me.
c. And if you could choose between one extra life-year gained one-year from now or three extra life years gained 40 years from now, what would you choose?
A: One extra life-year gained one-year from now
B: Three extra life years gained 40 years from now
C: Both options are equal to me.
d. And if you could choose between one extra life-year gained one-year from now or four extra life years gained 40 years from now, what would you choose?
A: One extra life-year gained one-year from now
B: Four extra life years gained 40 years from now
C: Both options are equal to me.
e. And if you could choose between one extra life-year gained one-year from now or five extra life years gained 40 years from now, what would you choose?
A: One extra life-year gained one-year from now
B: Five extra life years gained 20 years from now
C: Both options are equal to me.
f. According to your answers, gaining one life–year one-year from now has an equal value to gaining one to five life years 40 years from now. (Range is being determined by the software from above answers, range shown is example)
We would like you to indicate on the scale below, the exact amount of life years gained between one life-year and five life years, which, if received 40 years from now, would have the exact same value to you as a gain of one life-year one-year from now.
Part D
Part D contains questions on your future expectations in general.
D.1 Question on living in good health
At the moment, people in the Netherlands live on average 65 years in good health conditions. Please fill in the number of years you expect people in the Netherlands to live in good health in 5, 10, 20, and 40 years.
D.2 Question on life expectancy
At the moment people in the Netherlands, on average, reach the age of 79 years old. Please fill in the average age, you expect people in the Netherlands will reach 5, 10, 20, and 40 years from now.
D.3 Question on income
At the moment, the average income in the Netherlands is €32.500 per year. Please fill in the average income you expect to be earned in the Netherlands 5, 10, 20, and 40 years from now.
Thank you kindly for your cooperation