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.
