Cost Containment and QALYs 1 What s a

Cost Containment and QALYs 1

What’s a “good” buy? “Expensive” more than $100, 000/QALY “Reasonable” $50, 000/QALY (UK upper limit ~ $47, 000) “Very Efficient” less than $25, 000/QALY Most writers use $50 -100, 000 as upper limit of good value, but public preferences suggest upper limit over $200, 000 Hirth RA, et al. , Medical Decision Making. 2000; 20: 332 -342 2

Some sample QALYs (2002 dollars) Harvard Public Health Review (Fall 2004) n < $0 (If the cost per QALY is less than zero, the intervention actually savesmoney) n n Under $10, 000 n n n Antihypertensive medications in adults age 35 -64 with high blood pressure bu no coronary heart disease Lung transplant in. UK (Anyanwu AC et al. Thorac Cardiovasc Surg J 2002; 123: 411 -420) $50, 000 -$ 100, 000 n n n Colonoscopyevery five to 10 years for women age 50 and up $20, 000 to $ 50, 000 n n Combinationantiretroviral therapy for certain patients HIV $15, 000 to $ 20, 000 n n Beta-blockerdrugs post-heart attack in high-risk patients $10, 000 to $ 20, 000 n n Flu vaccine for the elderly Dialysis for patients with end-stage kidney disease Antibioticprophylaxis during dental procedures for persons at moderate to hi risk of bacterial endocarditis ($88, 000) (Med Decis Making. 2005; 25(3): 308 -2 Over $ 500, 000 n CT and MRI scans forkids with headache and an intermediate risk of brain tumor 3

COST/QALY: Selected Medicare services Condition/Treatment Cost per QALY Treatment for Erectile Dysfunction $6, 400/QALY *Physician Counseling for Smoking $7, 200/QALY Total Hip Replacement $9, 900/QALY *Outreach for Flu and Pneumonia $13, 000/QALY Treatment of Major Depression $20, 000/QALY Gastric Bypass Surgery $20, 000/QALY Treatment for Osteoporosis $38, 000/QALY *Screening For Colon Cancer $40, 000/QALY Implantable Cardioverter Defibrillator $75, 000/QALY Lung-Volume Reduction Surgery $98, 000/QALY Tight Control of Diabetes $154, 000/QALY *Treating Elevated Cholesterol ( + 1 risk factor) $200, 000/QALY Resuscitation After Cardiac Arrest $270, 000/QALY Left Ventricular Assist Device $900, 000/QALY 4

Cost of treatment for metastatic colon cancer (Schrag D. NEJM. 2004; 351: 317 -319 ) 5

Examining the cost and cost-effectiveness of adding bevacizumab (Avastin) to chemo in metastatic colon cancer n n n Randomized trial compared chemotherapy alone vs. chemotherapy + bevacizumab Bevacizumab regimen prolonged median survival from 15. 6 to 20. 3 months (p<0. 001) Cost of extra 4. 7 months? n n $101, 500 (assuming $5, 000 per month for bevacizumab) $259, 149 per year of life gained (not quality adjusted) n NICE decided not to recommend for NHS coverage 6

Examining the cost and cost-effectiveness of adding bevacizumab (Avastin) to chemo in advanced non-small cell lung cancer n n n Randomized trial compared chemotherapy alone vs. chemotherapy + bevacizumab Bevacizumab regimen prolonged median survival from 10. 2 to 12. 5 months (p=0. 007) Cost of extra 2. 3 months? n n $66, 270 -$80, 343 $345, 762 per year of life gained (assuming $66, 270 cost) n Grusenmeyer PA, Gralla RJ. J. Clin. Oncology. 2006; 24(18 S): 6057. 7

Can we make QALY-based decisions? n Cost-effectiveness decisions are controversial n n Prohibited under PPACA from being used as sole basis for denying coverage in federal programs (§ 6301) Oregon Health Care Plan n n Mammography screening guidelines in 2009 (page 149) n n Ended up with fairly generous “basic” coverage US Preventive Services Task Force recommended that routine screening begin at age 50 instead of age 40 The “tragic choices” problem n It’s difficult to make life-and-death decisions openly 8

What is a QALY? Major stroke 0 1 Perfect health Dead Recurrent stroke Studying for a law school exam 9