Decision Makers’ Attitudes
to Cost Effectiveness
Analysis
Shoshanna Sofaer, Dr.P.H.
School of Public Affairs
Baruch College
The Research Team
 Marthe
R. Gold, M.D., M.P.H., Principal
Investigator, Sophie Davis Medical
College, City College of New York
 Stirling Bryan, Ph.D., University of
Birmingham, UK
 Shoshanna Sofaer, Dr.P.H., School of
Public Affairs, Baruch College
 Taryn Siegelberg, M.P.P., Sophie Davis
Medical College, City College of New York
June 5, 2007
Academy Health Annual Research
Meeting
2
Overview
 Study
Background and Purpose
 Methods
 Findings


Quantitative
Qualitative
 Implications
June 5, 2007
Academy Health Annual Research
Meeting
3
Background
 Cost
effectiveness analysis (CEA) is rarely
used to make coverage decisions in the
US, although it is increasingly used in
other developed nations. Why?
 This study explored the attitudes of
decision makers in the public and private
sectors, in California, to CEA, to identify
both support for this approach and barriers
to its use.
June 5, 2007
Academy Health Annual Research
Meeting
4
Background
 Study
funded by the California Health
Care Foundation; additional support
provided through The Commonwealth
Fund through a Harkness Fellowship
provided to Stirling Bryan, Ph.D., health
economist and participant in the British
National Institute for Clinical Excellence
(NICE)
June 5, 2007
Academy Health Annual Research
Meeting
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Methods
 Mixed
method study
 Six half-day workshops with California
decision makers, including





Health plans/insurers
Purchasers
State Medicaid
State Health Plan Regulator
Multi-stakeholder coalition
June 5, 2007
Academy Health Annual Research
Meeting
6
Methods
 Workshop




included:
Primer on CEA
Discussion of cases that reveal ethical issues
inherent in CEA
Presentation of information on the CE ratios
of 14 condition-treatment pairs
Request for participants to act as “social”
decision makers vis a vis the Medicare
program
June 5, 2007
Academy Health Annual Research
Meeting
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Methods

Also,



Discussion of the work of NICE
Discussion of benefits and barriers to CEA in
participants’ own organizational context
Workshops



Included a range of senior decision makers (clinical
and non-clinical); average n = 10; total n = 58
Lasted about 2.5 hours
Were moderated by Dr. Bryan and either Dr. Gold or
Dr. Sofaer or both
June 5, 2007
Academy Health Annual Research
Meeting
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Methods

Prior to workshop, participants got descriptions
of the 14 condition-treatment pairs with
information about their effectivness vis a vis
Medicare population
 They rank-ordered the 14: 5 definitely cover; 5
probably cover; 4 definitely not cover
 They were also surveyed vis a vis
demographics, attitudes and knowledge of CEA
June 5, 2007
Academy Health Annual Research
Meeting
9
Methods

After the workshop

Second survey, with some of the same questions plus
additional questions about the workshop and about
problems with CEA

Workshop discussions transcribed; discussion of
benefits and barriers coded using NVivo
 Pre- and post-surveys analyzed descriptively
and comparatively
 Rankings analyzed in terms of the difference in
CEA ratio between treatment that received high
and low priority, before and after CEA ratios
were available
June 5, 2007
Academy Health Annual Research
Meeting
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Findings

While 57% said they understood CEA at least
reasonably well before the workshop, 91% rated
themselves at that level after the workshop
 While 51% said they personally supported
health care rationing before the workshop, 59%
said they supported it afterwards
 In post workshop survey:



72% said CEA should be used in all coverage
decisions, not just new treatments
91% said it should be used in Medicare coverage
decisions
75% said it should be used by private health plans
June 5, 2007
Academy Health Annual Research
Meeting
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Findings

Prior to the workshop, the median difference in
the CEA ratios of treatments participants said
they would cover and those they said they would
not cover was $37,000
 After the workshop, the median difference grew
to $247,000 (p,0.001 using non-parametric
statistics)
 Thus, people were more likely, after receiving
CE information, to cover more cost-effective
treatments and choose not to cover less costeffective treatments.
June 5, 2007
Academy Health Annual Research
Meeting
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400,000
300,000
200,000
100,000
0
-100,000
-200,000
-300,000
Diff QALY score 1
June 5, 2007
Academy Health Annual Research
Meeting
Diff QALY score 2
13
Findings
So then why don’t we use CEA?
 Discussion and post-workshop survey identify
key barriers among these organizations
 In post-workshop survey, the following were
identified as important barriers by at least twothirds of respondents:




Disconnect between long-term perspective of CEA
and short-term perspective of most decision makers
The risk of litigation
Commercial sponsorship of CEA studies of products
June 5, 2007
Academy Health Annual Research
Meeting
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Findings
 Other
barriers emerging in qualitative
analysis of discussion:


Americans will find cost unacceptable as a
basis for coverage decisions (a special
problem for health plans vis a vis market
share)
No single private sector entity can “go it
alone” – someone, e.g. Medicare, has to take
the lead on this major societal issue
June 5, 2007
Academy Health Annual Research
Meeting
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Implications
 Decision
makers may be more open than
we think to using CEA
 Our other research indicates that the
public can also (through similar
workshops) learn enough about CEA to
understand it, discuss it, recognize its
problems and limits, but then respond like
the decision makers to CEA information
June 5, 2007
Academy Health Annual Research
Meeting
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Implications
The term “cost-effectiveness” is widely misused
(e.g. for cheap or cost-saving)
 It also carries the “baggage” of the term
“rationing”
 Action is needed to:




Increase understanding of CEA among the public and
decision makers?
Create an environment in which it is “safe” to use
CEA as ONE input to coverage decisions?
Encourage the Medicare program to examine the
advantages of CEA as a cost-constraining device that
may not have as many deleterious effects on access
and quality as other options?
June 5, 2007
Academy Health Annual Research
Meeting
17