The incremental cost-effectiveness ratio (ICER) threshold serves as a crucial reference point for decision-makers to assess whether healthcare interventions demonstrate an appropriate relationship between costs and benefits, forming an important basis for a sustainable healthcare system. It represents a fundamental economic concept of opportunity costs, interpreted both as foregone benefits from alternative resource use and as additional resources society is willing to invest in health effects.

This report examines the implementation and implications of ICER thresholds in healthcare resource allocation decisions across different healthcare systems. Through comprehensive analysis of literature, policy documents, and health economic guidelines from various countries, the research explores theoretical foundations, practical applications, and methods for determining these thresholds. Among 39 analysed countries, 24 employ thresholds in their decision-making processes, with values ranging from €4000 to €50,000 per quality-adjusted life year (QALY). Most countries utilise either threshold ranges or multiple baseline thresholds, and many incorporate modifiers to account for factors beyond pure health maximisation. Ten distinct modification criteria were identified, and while twelve countries utilise quantitative modifiers that increase the threshold or ICER, six countries have officially established qualitative modifiers, with three countries employing both types of modifiers. The report reveals interesting relationships between thresholds, healthy life expectancy, and gross domestic product (GDP) per capita, suggesting complex interactions between economic factors and health outcomes.

In Austria, health economic evaluations have played a minor role and have only formally been required in specific cases, primarily in the assessment of outpatient pharmaceuticals. Whilst efficiency concepts ("Wirtschaftlichkeit") are anchored in various laws, they are rarely operationalised concretely. The research identifies key success factors for implementation, including the development of detailed methodological guidelines, capacity building, and creating awareness about the distinction between resource rationing and efficient utilisation. The report concludes that whilst implementing thresholds is complex, it can contribute to greater transparency and efficiency in healthcare systems, though careful consideration must be given to methodological options and country-specific contexts.