Hostname: page-component-cd9895bd7-p9bg8 Total loading time: 0 Render date: 2024-12-23T04:32:19.141Z Has data issue: false hasContentIssue false
  • English
  • Français

Has the time come for cost-effectiveness analysis in US health care?

Published online by Cambridge University Press:  01 October 2009

STIRLING BRYAN ,
SHOSHANNA SOFAER ,
TARYN SIEGELBERG  and
MARTHE GOLD
STIRLING BRYAN
Affiliation:
University of British Columbia, Canada
SHOSHANNA SOFAER
Affiliation:
Baruch College, City University of New York, USA
TARYN SIEGELBERG
Affiliation:
City College, City University of New York, USA
MARTHE GOLD*
Affiliation:
City College, City University of New York, USA
*
*Corresponding author: Marthe Gold, MD, MPH, Department of Community Health and Social Medicine, City College, City University of New York Medical School, 138th Street and Convent Avenue, Harris 406, New York, NY 10031, USA. Email [email protected]
Get access Rights & Permissions [Opens in a new window]

Abstract

Cost-effectiveness analysis (CEA) is a powerful analytic tool for assessing the value of health care interventions but it is a method used sparingly in the US. Despite its growing acceptance internationally and its endorsement in the academic literature, most policy analysts have assumed that US decision makers will resist using CEA to inform coverage decisions. This study sought to clarify the extent to which CEA is understood and accepted by US decision makers, including regulators, private and public insurers, and purchasers, and to identify their points of difficulty with its use. We conducted half-day workshops with a sample of six California-based health care organizations that spanned a range of public and private perspectives regarding coverage of health care services. Each workshop included an overview of CEA methods, a priority-setting exercise that asked participants (acting as ‘social decision makers’) to rank condition treatment pairs prior to and following provision of cost-effectiveness information; and a facilitated discussion of obstacles and opportunities for using CEA in their own organizations. Pre and post-questionnaires inquired as to obstacles toward implementing CEA, attitudes toward rationing, and views on the use of CEA in Medicare and in private insurance coverage decision-making. In post-workshop surveys major obstacles identified included: fears of litigation, concerns about the quality and accuracy of studies that were commercially sponsored, and failure of CEAs to address shorter horizon cost implications. Over 90% of participants felt that CEA should be used as an input to Medicare coverage decisions and 75% supported its use in such decisions by private insurance plans. Despite the wide acceptance of CEA, at the conclusion of the workshop, 40% of the sample remained uncomfortable with support of ‘rationing’ per se. We suggest that how cost-effectiveness analysis is framed will have important implications for its acceptability to US decision makers.

Type
Articles
Information
Health Economics, Policy and Law , Volume 4 , Issue 4 , October 2009 , pp. 425 - 443
Copyright
Copyright © Cambridge University Press 2009

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Aaron, H., Schwartz, W., and Cox, M. (2005), Can We Say No? The Challenge of Rationing Health Care, Washington, DC: Brookings Institution Press.Google Scholar
Al, M.J., Feenstra, T., and Brouwer, W.B. (2004), ‘Decision makers’ views on health care objectives and budget constraints: results from a pilot study’, Health Policy, 70(1): 33–48.CrossRefGoogle ScholarPubMed
Aspinall, S.L., Good, C.B.,Glassman, P.A., and Valentino, M.A. (2005), ‘The evolving use of cost-effectiveness analysis in formulary management within the department of veterans affairs’, Medical Care, 43(7 Suppl), 20–26.CrossRefGoogle ScholarPubMed
Banta, H.D. and Luce, B.R. (1983), ‘Assessing the cost-effectiveness of prevention’, Journal of Community Health, 9(2): 145–165.CrossRefGoogle ScholarPubMed
Bell, C.M., Urbach, D.R.Ray, J.G.,Bayoumi, A.,Rosen, A.B.Greenberg, D., and Neumann, P.J. (2006), ‘Bias in published cost effectiveness studies: systematic review’, British Medical Journal, 332(7543): 699–703.CrossRefGoogle ScholarPubMed
Bloche, M.G. and Jacobson., P.D. (2000), ‘The Supreme Court and bedside rationing’, Journal of the American Medical Association, 284(21): 2776–2779.CrossRefGoogle ScholarPubMed
Brock, D. (1998), ‘Ethical issues in the development of summary measures of population health status’, in Institute of Medicine (ed.), Summarizing Population Health: Directions for the Development and Application of Population Metrics, Washington, DC: National Academy Press, pp. 73–91.Google Scholar
Bryan, S., Williams, I.P., and McIver, S. (2007), ‘Seeing the NICE side of cost-effectiveness analysis: a qualitative investigation of the use of CEA in NICE technology appraisals’, Health Economics, 16(2), 179–193.CrossRefGoogle ScholarPubMed
Daniels, N. (1985), Just Health Care, editor Walker, D.Cambridge, MA: Harvard University Press.CrossRefGoogle ScholarPubMed
Daniels, N. and Sabin, J. (2002), Setting Limits Fairly: Can We Learn to Share Medical Resources? New York: Oxford University Press.CrossRefGoogle Scholar
Foote, S.B. (2002), ‘Why Medicare cannot promulgate a national coverage rule: a case of regulamortis’, Journal of Health Politics, Policy and Law, 27(5): 707–730.CrossRefGoogle Scholar
Garber, A.M. (2001), ‘Evidence-based coverage policy’, Health Affairs (Millwood), 20(5): 62–82.CrossRefGoogle ScholarPubMed
Garber, A.M. (2004), ‘Cost-effectiveness and evidence evaluation as criteria for coverage policy’, Health Affairs (Millwood) Suppl Web Exclusives (W4): 284–296.Google ScholarPubMed
Gillick, M.R. (2004), ‘Medicare coverage for technological innovations – time for new criteria?’, New England Journal of Medicine, 350(21): 2199–2203.CrossRefGoogle ScholarPubMed
Gold, M.R., Stevenson, D. and Fryback, D.G. (2002), ‘HALYS and QALYS and DALYS, oh my: similarities and differences in summary measures of population health’, Annual Review of Public Health, 23: 115–134.CrossRefGoogle Scholar
Gold, M.R., Franks, P., Siegelberg, T., and Sofaer, S. (2007), ‘Does providing cost-effectiveness information change coverage priorities for citizens acting as social decision makers?’, Health Policy, 83(1): 65–72.CrossRefGoogle ScholarPubMed
Gold, M.R., Sofaer, S. and Siegelberg, T. (2007), ‘Medicare and cost-effectiveness analysis: time to ask the taxpayers’, Health Affairs, 26(5): 1399–1406.CrossRefGoogle ScholarPubMed
Hadorn, D.C. (1991), ‘Setting health care priorities in Oregon: cost-effectiveness meets the rule of rescue’, Journal of the American Medical Association, 265(17): 2218–2225.CrossRefGoogle ScholarPubMed
Harris, J. (1987), ‘QALYfying the value of life’, Journal of Medical Ethics, 13(3): 117–123.CrossRefGoogle ScholarPubMed
Harris, J. (1988), ‘Life: quality, value and justice’, Health Policy, 10(3): 259–266.CrossRefGoogle ScholarPubMed
Henry, D.A., Hill, S.R. and Harris, A. (2005), ‘Drug prices and value for money: the Australian Pharmaceutical Benefits Scheme’, Journal of the American Medical Association, 294(20): 2630–2632.CrossRefGoogle ScholarPubMed
Jacobson, P.D. and Kanna, M.L. (2001), ‘Cost-effectiveness analysis in the courts: recent trends and future prospects’, Journal of Health Politics, Policy and Law, 26(2): 291–326.CrossRefGoogle ScholarPubMed
Jones, S.B. (1996), ‘Medicare influence on private insurance: good or ill?’, Health Care Financing Review, 18(2): 153–161.Google ScholarPubMed
Kassirer, J.P. and Angell, M. (1994), ‘The journal's policy on cost-effectiveness analyses’, New England Journal of Medicine, 331(10): 669–670.CrossRefGoogle ScholarPubMed
Koch, T. (2000), ‘Life quality v. the “quality of life”: assumptions underlying prospective quality of life instruments in health care planning’, Social Science and Medicine, 51(3): 419–427.CrossRefGoogle Scholar
Luce, B.R. (2005), ‘What will it take to make cost-effectiveness analysis acceptable in the United States?’, Medical Care, 43(7 Suppl): 44–48.CrossRefGoogle ScholarPubMed
Menzel, P., Gold, M.R.Nord, E., Pinto-Prades, J.L., Richardson, J., and Ubel, P. (1999), ‘Toward a broader view of values in cost-effectiveness analysis of health’, Hastings Center Report, 29(3): 7–15.CrossRefGoogle Scholar
Miners, A.H., Garau, M., Fidan, D. and Fischer, A.J. (2005), ‘Comparing estimates of cost effectiveness submitted to the National Institute for Clinical Excellence (NICE) by different organizations: retrospective study’, British Medical Journal, 330(7482): 65.CrossRefGoogle Scholar
Neumann, P.J. (2004a), ‘Evidence-based and value-based formulary guidelines’, Health Affairs (Millwood), 23(1): 124–134.CrossRefGoogle ScholarPubMed
Neumann, P.J. (2004b), ‘Why don't Americans use cost-effectiveness analysis?’, American Journal of Managed Care, 10(5): 308–312.Google ScholarPubMed
Neumann, P.J., Rosen, A.B. and Weinstein, M.C. (2005), ‘Medicare and cost-effectiveness analysis’, New England Journal of Medicine, 353(14): 1516–1522.CrossRefGoogle ScholarPubMed
Neumann, P. (2005), Using Cost-Effectiveness Analysis to Improve Health Care, New York, NY: Oxford University Press.Google Scholar
Neumann, P.J., Palmer, J.A.,Daniels, N., Quigley, K.Gold, M.R., and Chao, S. for the Panel on Integrating Cost-Effectiveness Considerations into Health Policy Decisions (2008), ‘A strategic plan for integrating cost-effectiveness analysis into the US healthcare system’, American Journal of Managed Care, 14(4): 185–188.Google ScholarPubMed
Nord, E., Pinto, J.L.Richardson, J.Menzel, P. and Ubel, P. (1999), ‘Incorporating societal concerns for fairness in numerical valuations of health programmes’, Health Economics, 8(1): 25–39.3.0.CO;2-H>CrossRefGoogle ScholarPubMed
Prosser, L.A., Koplan, J.P.Neumann, P.J. and Weinstein, M.C. (2000), ‘Barriers to using cost-effectiveness analysis in managed care decision making’, American Journal of Managed Care, 6(2): 173–179.Google ScholarPubMed
Rawles, J. (1989), ‘Castigating QALYs’, Journal of Medical Ethics, 15(3): 143–147.CrossRefGoogle ScholarPubMed
Reinhardt, U.E. (1997), ‘Making economic evaluations respectable’, Social Science and Medicine, 45(4): 555–562.CrossRefGoogle ScholarPubMed
Rawlins, M. (1999), ‘In pursuit of quality: the National Institute for Clinical Excellence’, Lancet, 353(9158): 1079–1082.CrossRefGoogle ScholarPubMed
Rawlins, M.D. (2005), ‘Pharmacopolitics and deliberative democracy’, Clinical Medicine, 5(5): 471–475.CrossRefGoogle ScholarPubMed
Ross, J. (1995), ‘The use of economic evaluation in health care: Australian decision makers’ perceptions’, Health Policy, 31(2): 103–110.CrossRefGoogle ScholarPubMed
Russell, L.B., Gold, M.R., Siegel, J.E.Daniels, N., and Weinstein, M.C. (1996), ‘The role of cost-effectiveness analysis in health and medicine: panel on Cost-Effectiveness in Health and Medicine’, Journal of the American Medical Association, 276(14): 1172–1177.CrossRefGoogle ScholarPubMed
Sacramento Healthcare Decisions. (2006), ‘Getting good value: consumers debate costly treatments: is it worth the expense?’, Available at http://www.sachealthdecisions.org/docs/ggv_report.pdfGoogle Scholar
Saha, S., Hoerger, T.J., Pignone, M.P.Teutsch, S.M.Helfand, M., and Mandelblatt, J.S. (2001), ‘The art and science of incorporating cost effectiveness into evidence-based recommendations for clinical preventive services’, American Journal of Preventative Medicine, 20(3 Suppl): 36–43.CrossRefGoogle ScholarPubMed
Schauffler, H.H. (1993), ‘Disease prevention policy under Medicare: a historical and political analysis’, American Journal of Preventative Medicine, 9(2): 71–77.CrossRefGoogle ScholarPubMed
Siegel, J.E. (2005), ‘Cost-effectiveness analysis in US healthcare decision-making: where is it going?’, Medical Care, 43(7 Suppl): 1–4.CrossRefGoogle ScholarPubMed
Task Force on Principles for Economic Analysis of Health Care Technology (1995), ‘Economic analysis of health care technology: a report on principles’, Annals of Internal Medicine, 123(1): 61–70.CrossRefGoogle Scholar
Tunis, S.R. (2004), ‘Why Medicare has not established criteria for coverage decisions’, New England Journal of Medicine, 350(21): 2196–2198.CrossRefGoogle Scholar
Tunis, S.R. (2007), ‘Reflections on science, judgment, and value in evidence-based decision making: a conversation with David Eddy’, Health Affairs, Web Exclusive, 19 June 2007, w500–w515.CrossRefGoogle Scholar
US Congress (1992), ‘Evaluation of the Oregon medicaid proposal’, in OTA-H-531, Office of Technology Assessment, Washington, DC: US Congress.Google Scholar
Wallace, J.F., Weingarten, S.R., Chiou, C.F.Henning, J.M., Hohlbauch, A.A.Richards, M.S.Herzog, N.S., Lewensztain, L.S., and Ofman, J.J. (2002), ‘The limited incorporation of economic analyses in clinical practice guidelines’, Journal of General Internal Medicine, 17(3): 210–220.CrossRefGoogle ScholarPubMed
WellPoint (2005), National Pharmacy and Therapeutics Committee, www.wellpointnextrx.com/shared/noapplication/f1/s0/t0/pw_ad080613.pdfGoogle Scholar