OBJECTIVES: The “ISPOR Value Flower” was presented in response to the limitation of the standard cost per QALY approach that does not incorporate all value elements relevant from an economic perspective. The ”flower” introduces 12 value elements whereof 8 are potentially novel. This study is a review of published, empirical studies of the novel elements in order to assess their relative importance and potential overlap.

METHODS: A review of the literature was performed by applying iteratively defined search terms found in articles, in addition to searching for cross-references (“pearl-growing”).

RESULTS: The insurance value was found to be the dominant value element. Standard cost per QALY approach was found to capture as little as 20% of the total value in some studies and including insurance value could increase value by a factor of 2-3. Moreover, insurance value could incorporate significant parts of other potentially novel value elements including severity, real option value and equity.

CONCLUSIONS: The result of this study suggest that excluding insurance value leads to a significant underestimation of true value from an economic perspective. This applies to all types of health care technologies but can be expected to be especially relevant for new medical technologies with potentially large health benefits aimed at severe, rare diseases. Future research and discussions are needed to find the best approach to incorporate insurance value. Whether to adjust QALY estimates, adding separate values in addition to QALY estimates, or replacing QALY estimates with willingness-to-pay (WTP).