The Lynx Group

Cost-Effectiveness in the New Comparative Effectiveness Landscape

September 2010, Vol 1, No 4

Boston, MA—Cost-effectiveness can still add value in the comparative effectiveness landscape without it becoming woven into the politically caustic concept of healthcare allocation, according to 4 experts from academia, industry, and governmental agencies. The future of cost-effectiveness in the larger universe of comparative effectiveness research in a post–healthcare reform world was debated during a roundtable discussion at the AcademyHealth conference in Boston.

A Suddenly Toxic Methodology

Steven Pearson, MD, president and founder of the In stitute for Clinical and Economic Review, Harvard Medical School, Boston, MA, noted the restrictions placed on the use of cost-effectiveness during the healthcare reform debate.

“Wow, cost-effectiveness really took an arrow to the heart,” Dr Pearson said. As stated by the new independent, non governmental Patient-Centered Outcomes Research Institute, healthcare policy cannot “develop or use dollars per quality-adjusted life-year as a threshold to establish what type of healthcare is cost-effective or recommended.”

If that is the case, does cost-effectiveness analysis (CEA) have a future? “We’re on a precipice…a policy window of sorts, and while that window is open, lots of creative activities can take place,” said Jean Slutsky, director of the Centers for Outcomes and Evidence, Agency for Healthcare Research and Quality, Rockville, MD.

Given this new reality, Dr Pearson suggested that “impact on service” is one way that patients would find CEA helpful. “Certain prostate cancer therapies involve 1 overnight hospital stay and a few doctor visits down the road; others involve a daily doctor’s visit for up to 6 to 8 weeks,” he noted. “Just putting that down can be powerful.” Assessing the cost to reduce side effects is another example. “If you’ve got 2 different agents [for] the same thing and one has a lower rate of side effects but is more expensive, how much are we spending to reduce that risk of a side effect?” he wondered.

Ms Slutsky asserted that CEA desperately needs to overhaul its public image. “We’ve allowed all these tags to be associated with it, and it’s now become a public relations game, not an information game,” she said. Acknowledging that “it’s the terminology that gets a little tricky,” she said that “transparency is needed so the public knows how we come to cost conclusions. I really can’t emphasize enough how much we need effective communication so it comes across in a nonthreatening way.”

Putting Cost-Effectiveness in the Equation

Lewis Sandy, MD, senior vice president of clinical advancement at UnitedHealth Group, Minneapolis, MN, described how separating clinical value from cost-effectiveness is used to determine the benefits his company provides. UnitedHealth Group’s different committees research the clinical value of a procedure, device, or drug by asking questions including:

  • Does it work?
  • How strong is the evidence?
  • What are the outcomes?
  • How does it work in the real world?

“This clinical value calculus affects coverage decisions,” he said. “Is the product included in the envelope for benefit coverage? Cost-effectiveness can affect how it is covered—what is the benefit level and structure?” Dr Sandy expressed hope that CEA will be in the examination room in the future, when the patient needs to make a high-stakes choice. “Comparative effectiveness needs to support optimal decision-making between doctors and patients,” he argued, adding that it should foster “a dialogue about evidence and an elicitation of preferences.”

Hemal Shah, PharmD, executive director of health economics and outcomes research at Boehringer Ingelheim, Ridgefield, CT, concurred with Dr Sandy that cost and value should be evaluated only after clinical outcomes are assessed. Using CEA to determine a one-size-fits-all measure of value is impractical, she argued, and instead should be done at regional or local levels. “Depending on the region and practice patterns, you’ll see very different ways cost and utilization are observed,” Dr Shah noted.

Dr Pearson summed up the future of cost-effectiveness. “The United States has largely ignored how it uses its re sources for healthcare,” he said. “If we feel we’re on an unsustainable path, what are the ways we can engage the public in a dialogue about some of those issues? Cost-effectiveness is not thought of as a method, it’s thought of as a form of decision-making. We may want to rename it and think of it in new terms.”

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