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



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.


Corresponding author

*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


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Aaron, H., Schwartz, W., and Cox, M. (2005), Can We Say No? The Challenge of Rationing Health Care, Washington, DC: Brookings Institution Press.
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): 3348.
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), 2026.
Banta, H.D. and Luce, B.R. (1983), ‘Assessing the cost-effectiveness of prevention’, Journal of Community Health, 9(2): 145165.
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): 699703.
Bloche, M.G. and Jacobson., P.D. (2000), ‘The Supreme Court and bedside rationing’, Journal of the American Medical Association, 284(21): 27762779.
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.
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), 179193.
Daniels, N. (1985), Just Health Care, editor Walker, D.Cambridge, MA: Harvard University Press.
Daniels, N. and Sabin, J. (2002), Setting Limits Fairly: Can We Learn to Share Medical Resources? New York: Oxford University Press.
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): 707730.
Garber, A.M. (2001), ‘Evidence-based coverage policy’, Health Affairs (Millwood), 20(5): 6282.
Garber, A.M. (2004), ‘Cost-effectiveness and evidence evaluation as criteria for coverage policy’, Health Affairs (Millwood) Suppl Web Exclusives (W4): 284296.
Gillick, M.R. (2004), ‘Medicare coverage for technological innovations – time for new criteria?’, New England Journal of Medicine, 350(21): 21992203.
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: 115134.
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): 6572.
Gold, M.R., Sofaer, S. and Siegelberg, T. (2007), ‘Medicare and cost-effectiveness analysis: time to ask the taxpayers’, Health Affairs, 26(5): 13991406.
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): 22182225.
Harris, J. (1987), ‘QALYfying the value of life’, Journal of Medical Ethics, 13(3): 117123.
Harris, J. (1988), ‘Life: quality, value and justice’, Health Policy, 10(3): 259266.
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): 26302632.
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): 291326.
Jones, S.B. (1996), ‘Medicare influence on private insurance: good or ill?’, Health Care Financing Review, 18(2): 153161.
Kassirer, J.P. and Angell, M. (1994), ‘The journal's policy on cost-effectiveness analyses’, New England Journal of Medicine, 331(10): 669670.
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): 419427.
Luce, B.R. (2005), ‘What will it take to make cost-effectiveness analysis acceptable in the United States?’, Medical Care, 43(7 Suppl): 4448.
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): 715.
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.
Neumann, P.J. (2004a), ‘Evidence-based and value-based formulary guidelines’, Health Affairs (Millwood), 23(1): 124134.
Neumann, P.J. (2004b), ‘Why don't Americans use cost-effectiveness analysis?’, American Journal of Managed Care, 10(5): 308312.
Neumann, P.J., Rosen, A.B. and Weinstein, M.C. (2005), ‘Medicare and cost-effectiveness analysis’, New England Journal of Medicine, 353(14): 15161522.
Neumann, P. (2005), Using Cost-Effectiveness Analysis to Improve Health Care, New York, NY: Oxford University Press.
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): 185188.
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): 2539.
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): 173179.
Rawles, J. (1989), ‘Castigating QALYs’, Journal of Medical Ethics, 15(3): 143147.
Reinhardt, U.E. (1997), ‘Making economic evaluations respectable’, Social Science and Medicine, 45(4): 555562.
Rawlins, M. (1999), ‘In pursuit of quality: the National Institute for Clinical Excellence’, Lancet, 353(9158): 10791082.
Rawlins, M.D. (2005), ‘Pharmacopolitics and deliberative democracy’, Clinical Medicine, 5(5): 471475.
Ross, J. (1995), ‘The use of economic evaluation in health care: Australian decision makers’ perceptions’, Health Policy, 31(2): 103110.
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): 11721177.
Sacramento Healthcare Decisions. (2006), ‘Getting good value: consumers debate costly treatments: is it worth the expense?’, Available at
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): 3643.
Schauffler, H.H. (1993), ‘Disease prevention policy under Medicare: a historical and political analysis’, American Journal of Preventative Medicine, 9(2): 7177.
Siegel, J.E. (2005), ‘Cost-effectiveness analysis in US healthcare decision-making: where is it going?’, Medical Care, 43(7 Suppl): 14.
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): 6170.
Tunis, S.R. (2004), ‘Why Medicare has not established criteria for coverage decisions’, New England Journal of Medicine, 350(21): 21962198.
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, w500w515.
US Congress (1992), ‘Evaluation of the Oregon medicaid proposal’, in OTA-H-531, Office of Technology Assessment, Washington, DC: US Congress.
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): 210220.
WellPoint (2005), National Pharmacy and Therapeutics Committee,
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