cea policy lecture2014
TRANSCRIPT
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Cost-efectivenessanalysis and health care
policyJulie Donohue, Ph.D.
Department o Health Policy &Management, !PH
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"utline
Do #e need cost-efectivenessanalysis$
Ho# do #e use cost-efectiveness%ndings to guide policy$
hy don't #e use cost-efectivenessino more$
hat can #e learn rom othercountries$
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Do #e need cost-
efectiveness analysis$
Health care spending in the
(!
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) large share o our economy isdevoted to health care
*n +, on healthcare #e spent
./0 o gross domestic product
123,4 per capita5
*n contrast, on education #e spent
.0 on primary, secondary, tertiaryeducation
SOURCES:Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group; and U.S. Departent of Coerce, !ureau of
"conoic Analysis and !ureau of the Census. O"CD
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e spend lots more than anyother country on health care
Anderson and Frogner 2008
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6et #e don't live as long as peoplein other countries
SOURCE: Aaron and Ginsburg Health Affairs 2009.
(By sae!
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hat are the do#nsides ogro#ing health care costs$
- Health insurance premiums go up
- e have less to spend on other
goods and services" 7ederal government
" !tate governments
" Households
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Health insurance premiums haveincreased much more than #or8ers'
earnings and in9ation
#rends in $ea%$ &are &oss and s'ending )aiser Fa*i%y Foundaion +ar&$ 2009
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)t ederal level:health care cro#ds out otherspending
2012 $
(billions)
2012 Share 2022 Share
Health care 2 3;4 ;0
Medicare Medicaid "ther
;?/+;3 +?
?0 0 0
+0+0 >0
!ocial !ecurity ?/ +0 +?0
"ther
Mandatory
? /0 >0
Discretionary ,>> >?0 +?0
@otal "utlays 2>,?> < 2;,+>?
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Gecent *"M report %nding
HGG-level Iuality is not consistentlyrelated to spending or utiliationamong either Medicare Aene%ciaries
or the commercially insured.K
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Ho# do #e use cost-efectiveness %ndings toguide policy$
ho should use CL) ino$
Ho# are health care costsdistriAuted$
Ho# do #e use CL) ino$
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ho should use cost-efectiveness inormation$
2004 Distribution of health spending by source of payment
Private
55.!Public
44.4!
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Comparative efectivenessresearch
) digression:
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CLG and cost-efectiveness
hen #e add data on 22 1cost-efectiveness5, CLG can help usallocate resources
hat should Ae covered Ay insurance$
7or #hom$
(nder #hat conditions$
Ho# much should consumers pay out opoc8et$
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(! has limited success in usingtechnology assessment
"regon Health Plan" is it Aetter or everyAody to have something than or some to
have a lot and others to have nothing$K
)gency or Health Care Gesearch and Policy 1no#)HGR5"
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Oimits on PC"G*
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hy don't #e use cost-
efectiveness ino more$
@ i d t i A l AA i
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@op industries Ay loAAyingependitures +/
O'ense&res.org
hat are the puAlic's
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hat are the puAlic'svie#s$
"n health care costs
"n #hether )mericans 1and theythemselves5 overtreated orundertreated
"n #ho should ma8e coveragedecisions
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Priorities or health reormeforts
)aiser /ea%$ #ra&?ing ;o%% Feb 2009
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6et the puAlic supportsincreased health spending
General Social Survey, 1973-2006
@ i i di l
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@oo many patients getting medicaltests & treatments that they don't
really need$
1;R)aiser Fa*i%y Foundaion/ar
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@oo many patients V"@ getting themedical tests & treatments that they
really need
1;R)aiser Fa*i%y Foundaion/ar
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Disconnect Aet#een nationalvie#s and personal eperience
1;R)aiser Fa*i%y Foundaion/ar
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*n last + years do you thin8 your doctorhas recommended:
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ho do you trust to reereeefectiveness$
#$ere $as been so*e dis&ussion abou $a
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@o sum up the politics
Oots o #ell-resourced interest groups#ho #ant to maintain the status Iuo
) puAlic #ho thin8s
" there are proAlems #ith the system, Aut
" they are getting really good care
" #e should proAaAly spend more not less
" government #on't ma8e the rightdecisions
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oals o health policy
" *mprove health 1reduce mortality andmorAidity, improve the Iuality o lie5
" LIuity W airness in the distriAution o health
care goods and services, in %nancing" LQciency W maimiing health suAEect to aAudget constraint
Vot something #e #ant or its o#n sa8e Aut
Aecause it helps us get more o #hat #e value@his is the goal emphasied Ay cost-efectiveness
analysis
P i l di
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Potential disputes overeIuity in coverage decisions
(sing CL) or Falue-
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Cost-efectiveness plane
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VL RuadrantX #hat is society #illingto pay per R)O6$
2;, per R)O6 Aenchmar8 oten cited
Ho#ever,
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hat can #e learn rom
other countries$
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V*CL 7unctions
Gecommends #ays to monitor clinicalperormance
*ssues clinical guidelines
" V*CL has issued / guidelines in last years
)ppraises clinical and cost-efectivenesso health technologies
" VH!' Primary Care @rusts #hich purchase carelocally are mandated to adopt V*CL'sappraisals
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Controversial coverage decisions
)vone or M! W not recommended or useAased on clinical and cost-efectiveness
" VH! adopted ris8 sharing scheme or
, patients !utent or 8idney cancer
Macugen or macular degeneration
" approved or use in one eye
Drugs or )lheimer's 1aricept5 only orpatients in early stages o disease
V*CL d i i t d t d
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V*CL decisions to date andimpact on costs
>> technology appraisals to dateMost are approved #ithout conditions
More than hal approved #ith restrictions
1limited to certain patient populations5Z;0 use restricted to clinical trials
Z0 not approved
*mpact on costs$@hey have gone up Ay +0 since
implementation o V*CL and other changes todelivery system
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C i i C
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CritiIues o V*CL1and similar eforts5
Places Aureaucrats Aet#een doctorsand patients
*t represents coo8 Aoo8K or onesie %ts allK medicine
Jeopardies physician autonomy
Gis8s #ith centralied decisionma8ing
" Lfect on G&D investments
Syre 200> 1eu*ann 200=
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Conclusions
Do #e need cost-efectiveness analysis$" 6L!. e can't aford not to in the long run
Ho# do #e use cost-efectiveness %ndings toguide policy$
" !hould at least use it to inorm Medicare coveragedecisions
hy don't #e use cost-efectiveness ino more$" *nterest groups and puAlic perceptions create Aarriers
hat can #e learn rom other countries$" challenge is to estaAlish the legitimacy o the
agencyNorganiation ma8ing the decisions