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Center for Prevention


                                                  Brief
and Health Services

        ISSUE                                                                                      August 2004




        Cost-Effectiveness Analysis:
        An Employer Decision Support Tool

                 This issue brief summarizes information presented at Cost-Effectiveness Analysis: An
                 Employer Decision Support Tool, a web-based seminar at the National Business Group
                 on Health sponsored by the Agency for Healthcare Research and Quality. Statistics
                 and figures that are not annotated with a source were presented by the speakers.

                 A glossary of italicized terms and a bibliography of additional cost-effectiveness resources
                 are listed at the end of the brief.


                                                      Introduction
        Table of Contents:                            Large employers face a challenging future in
        Introduction                              1   managing health care benefits. Managers have many
        Cost-Effectiveness Analysis Basics        2   program and coverage options, but are limited by
        Why Employers Use CEA                     3   budget constraints and data availability.
        Common Applications                       4
                                                      Traditionally, decision-makers have used return on
        S t r ategic Implicat i o n s             6
        Practical Examples                        9   investment calculations to help guide their
        S t r ategic Tips for Interpreting CEA   10   investment choices, but they can also consider
        Sample Abstract                          11   another tool — cost-effectiveness analysis.
        Case Studies                             12
        Conclusion                               14
                                                     Cost-effectiveness analysis (CEA) is a method of
        Glossary                                 15
        Resources                                17  financial evaluation that has gained prominence
        References                               19  within academic and policy communities in the last
                                                     20 years. But this methodology can also have
                                                     business applications as a decision support tool. This
                 issue brief explains cost-effectiveness analysis, outlines its usefulness to employers,
                 demonstrates how cost-effectiveness relates to corporate strategy, and gives examples
                 of its applications in health benefits decisions.
August 2004 ISSUE     Brief 2




Cost-Effectiveness Analysis Basics
Cost-effectiveness analysis is a specific type of economic analysis in which all costs are
related to a single, common effect. Decision makers can use it to compare different
resource allocation options in like terms. A general misconception is that CEA is merely a
means of finding the least expensive alternative or getting the “most bang for the buck.”
In reality, CEA is a comparison tool; it will not always indicate a clear choice, but it will
evaluate options quantitatively and objectively based on a defined model. CEA was
designed to evaluate health care interventions, but the methodology can be used for non-
health economic applications as well. It can compare any resource allocation with
measurable outcomes to any other
resource allocation with measurable
outcomes.
                                                  Cost-effectiveness analysis, or
Conducting, Evaluating, and                       CEA, is a comparison tool to help
Using Analyses                                    evaluate choices. It will not
                                                  always indicate a clear choice,
Increasing numbers of analyses are
                                                  but it will evaluate options
conducted in academia or research                 quantitatively based on a defined
organizations and published in                    model. For managers, CEA
peer-reviewed journals. Government                provides peer-reviewed evidence
organizations use analyses to help                for decision support.
shape public policy. Health insurers use
CEAs to determine which kinds of
health interventions to cover. There is
a growing body of work that quantitatively compares the health returned on different
interventions employers cover in their benefits packages. As employers are increasingly
asking providers to practice evidence-based medicine, they can direct this trend by
evaluating and acting on evidence, or by holding health plans and consultants accountable
for evaluation and action.
3 ISSUE   Brief August 2004




      Cost-Effectiveness Ratio
    The cost-effectiveness ratio is simply the sum of all benefits divided by the sum of all costs.
    This is comparable to a return on investment calculation; however, the benefits are not
    measured in terms of just dollars, but in a ratio that incorporates both health outcomes
    and dollars. Since healthier employees are more productive, improved outcomes actually
    do translate into dollars. But it is important to keep these values separate, so a decision
                                         maker can understand what kind of health benefit is
                                         returned on the investment. For instance, three
                                         investment choices could have cost-effectiveness ratios of
Cost-Effectiveness Ratio =
                                         $10,000/premature birth avoided, $20,000/workplace
         (All benefits)                  injury prevented, or $30,000/life year gained. The
                                         decision maker must then choose the health intervention
          (All costs)
                                         that is right in terms of budget and population health
                                         goals.

      CEAs compare several program strategies and then rank them by of cost-effectiveness
      ratios. An analysis of two screening interventions might show you that one costs
      $10,000/life year gained while the other costs $40,000/life year gained. The first
      intervention requires monthly screening and the second requires biannual screening.
      Realizing that compliance is a greater problem with monthly screening, the decision
      maker would have to implement the most appropriate coverage strategy for the population
      in question. Sometimes, the analysis compares to baseline options such as “do nothing” or
      “usual care.” Both are valid strategic options.


      Why Employers Use CEA
      Cost-effectiveness analysis:

      ✓ Supports objective decision making: Decision makers can consider options in a
        comparable and objective way that provides support for the final decision.

      ✓ Brings clarity to data sources and outcomes: CEA evaluates options in similar terms to
        avoid “comparing apples to oranges.”
August 2004 ISSUE     Brief 4




✓ Allows for strategic review of organizations: CEA might justify some operational
  centers operating at a loss to increase overall return on investment, employee health,
  or both.

✓ Can be used in a host of operational and benefits areas including:
  • Screening coverage
  • Pharmacy
  • Strategic Planning
  • Labor Relations
  • Disease Management
  • Disability Management
  • Wellness and Prevention Programs

✓ Presents evidence that can help gain support for changes in benefits plans or
  employer-sponsored health programs.


Common Applications
Evaluating Program Options
In the case of health screening, it is often difficult to determine the most cost-effective
frequency. Too frequent screening has high cost and possibly limited health benefits, while
too infrequent screening has low cost, but poor health outcomes. Determining
appropriate screening frequencies is a useful application of cost-effectiveness analysis. The
following table taken from an analysis on cervical cancer screening shows that life years
are saved at a relatively low cost in the first comparison (screening versus no screening),
but at a very high cost in the second comparison (the marginal cost and benefit of
decreasing the interval between screenings). Typically, an intervention that costs less than
$30,000/life year gained is considered cost-effective medicine. Based on this analysis,
cervical cancer screening every four years is a relatively cost-effective benefit to cover. It is
certainly more cost-effective than screening every three years.
5 ISSUE   Brief August 2004




   Table 1: Example Data from an Analysis of Cervical
   Cancer Screening Frequency


                                                             Screen every four years           Screen every three
                                                                vs. no screening             years vs. screen every
                                                                                                   four years

     Life expectancy increase, days                                    93.8                            1.6
     Life expectancy increase, days (discounted 5%)*                    9.5                            0.2
     Cost increase, dollars (discounted 5%)                            $264                           $91
     Cost per life year gained                                        $10,101                       $184,528

   Source: E d dy D.M. “Screening for Cervical Cancer,” Annals of Internal Medicine 1990; 113: 214-226.
   * Annual discount rat e adjust future costs and benefits to account for time preference and opportunity cost.

   Justifying Program Implementation
   When building a case to justify the use of funds, strong data is often compelling evidence.
   Cost-effectiveness analyses can be used to support qualitative arguments for health
   interventions. The following table examines a depression treatment improvement
   program. Treatment facilities in the study were offered training for practice leaders and
   nurses, enhanced educational and assessment resources, and trained psychotherapists for
   patient follow-ups. Not only was the intervention relatively cost-effective, but it also
   increased attendance in workers suffering from depression.

   Table 2: Example Data from an Analysis of a Depression
   Treatment Improvement Program

                                                                                            Quality improvement
                                                                                             program vs. usual
                                                                                                     care

     Quality-adjusted life year increase                                                            0.0226
     Cost increase                                                                                   $485
     Cost per quality adjusted life year                                                            $21,460
     Days of employment increase                                                                     20.9

   Source: Schoenbaum M. et al. “The Cost-effectiveness of Practice-Initiated Quality Improvement for Depression:
   Results from a Randomized, Controlled Trial,” JAMA 2001; 286: 1325-1330.
August 2004 ISSUE Brief   6




Cost-effectiveness analysis can be a valuable source of information and data for employers.
Most employers are not in the business of conducting analyses; however, it is reasonable to
expect carriers to rationalize and explain different coverage options in terms of cost-
effectiveness.


Strategic Implications
A System View
Because cost-effectiveness analysis examines a comprehensive set of costs and outcomes, it
is important to avoid narrow strategy that only considers implication for individual
department programs or cost centers. Managers can examine all parts of the health
benefits system to determine if financial losses in one area are recouped in another. For
example, dollars spent in richer benefit reimbursement might increase utilization and
avoid future costs of treatment.

The diagram below presents a system view of employer-sponsored health care.


                                   INPUTS
                                   • Diverse Workforce
                                   • Work Environment
                                   • HR & Benefits
                                   • Vendors & Providers




         Health                 Symptoms                   Diagnosis &           Benefit
        Behavior                & Disease                   Treatment        Reimbursement



                                   OUTPUTS
                                   • Health Stat u s
                                   • Productivity
                                   • Health Care Costs
                                   • Retention
                                   • Disability/Absenteeism
                                   • Presenteeism



Source: Michael Thompson, PricewaterhouseCoopers
7 ISSUE   Brief         August 2004




   Employers can use cost-effectiveness analysis to review each system component and
   choose the best strategy to optimize utilization, improve outcomes, and encourage
   healthier and more beneficial lifestyle choices.

   Strategic Readiness
   Unconventional methods like cost-effectiveness analysis are not an ideal fit for all
   organizations. Every company that provides health benefits has a different strategy for
   plan design and analysis. In some organizations, an attempt to incorporate cost-
   effectiveness analysis into decision making might be resisted or rejected altogether. To
   avoid such a misstep, assessment of corporate culture is necessary.

   The diagram below shows health care strategy as a continuum. Organizations that are
   more access-oriented analyze specific health care costs and delegate cost reduction
   responsibility to their carriers. Goals focus on controlling costs so that employers can
   continue to offer health care access through employee benefits. Organizations that are
   more system-oriented involve employees, employers, and health plans in dialogue about
   whole health management. Shared goals focus on increasing health and changing
   utilization patterns to control future costs.




              Access                                                             System
             Oriented                     Health Care Strategy                  Oriented
             Approach                                                           Approach

             Aware &                                                             E n g age &
                                                Leadership
             Inactive                                                              Enable

             Employee                                                             Share
                                                 Culture
              Benefit                                                          Responsibility

            Health Care                                                          Health &
           Access & Cost
                                                  Focus                        Performance

            Delegated                                                          Integrated &
           Accountability
                                               Health Plans                     Optimized

                            Source: Michael Thompson, PricewaterhouseCoopers
August 2004 ISSUE     Brief          8




To assess where large employers believe they lie on this continuum, a number of benefits,
health, and human resources professionals rated their organizations on a scale from 1
(mostly access-oriented) to 5 (mostly system-oriented) for the four component areas as
well as overall approach.
9 ISSUE   Brief           August 2004




  Practical Examples
  Pharmaceutical Formularies
  Employers can use CEA to compare specific drugs on their formularies or evaluate the
  cost-effectiveness of their entire pharmaceutical benefits packages. In comparing specific
  drugs, such as high-cost statins and beta-blockers, benefits managers address not only cost
  differences between brand name and generic, but disparities in effectiveness as well. This
  might include examining effectiveness per dose cost. For example, a particular statin may
  be the least expensive option per dose, but comparing it to other options in terms of cost
  and ability to reduce LDL levels may prove it is a less cost-effective choice (see Table 3).

  In analyzing an entire pharmacy program, employers determine costs for particular drugs
  in terms of tiers and responsibility. The recent trend has been for employers to shift more
  of the costs of medications to employees through higher co-pays or co-insurance, but this
  may not always be the most cost-effective long-term solution. Abandoning this strategy
  may create a financial loss on some prescriptions, but overall cost savings could be
  substantial if absenteeism, presenteeism, and disability are reduced in the process.
  Companies might also consider how they will price brand name drugs versus generics,
  especially for medications that have proven to be similar in safety and effectiveness.

  Table 3: Example Data from a Comparison of Six Statins


                                    Daily Dose (% LDL reduction/dose cost)

     Statin         5 mg               10 mg             20 mg           40 mg       80 mg
     Statin A       N/A                39%/$2.04         43%/$3.07       50%/$3.07   60%/$3.07
     Statin B       N/A                N/A               22%/$1.56       25%/$1.56   35%/$1.97
     Statin C       N/A                21%/$0.96         27%/$1.11       31%/$1.97   N/A
     Statin D       N/A                22%/$2.50         32%/$2.52       34%/$3.07   37%/$3.76
     Statin E       45%/$2.22          52%/$2.22         55%/$2.22       63%/$2.22   N/A
     Statin F       26%/$1.63          30%/$2.18         30%/$2.18       41%/$3.72   47%/$3.73

  Source: Michael Jacobs, Mercer Human Resource Consulting

  If decision makers were only looking for the lowest cost alternatives, they might select
  10mg of statin C. However, 40mg of statin E is the most cost-effective option. This
  dosage has the highest LDL reduction for the cost associated with it. Benefit managers
  can consider this information in making formulary decisions; however, this may not be
  the most favorable option when factors such as employee health characteristics, unions,
  and other issues weigh into the choice.
August 2004 ISSUE     Brief             10




Disease Management and Treatment
Cost-effectiveness analysis is a useful tool in developing and evaluating disease
management and treatment programs. It allows employers to determine objectively what
services to cover, for which populations, and how often. Employers, providers, and
insurers will normally seek the dominant choice — that choice which has lower costs and
better outcomes than other choices in the same situation. Often, lower costs may be
realized at the expense of outcomes, or better outcomes achieved at unacceptable costs. In
such cases, cost-effectiveness analysis can compare options and lead to smarter choices.
Employers and health plans can also use CEA to determine limits on coverage — for
what age, for which populations, how often, and other restrictions. A helpful reference for
such decisions may be the United States Preventive Services Task Force recommendations
for clinical services. The Task Force critically examines published research, including cost-
effectiveness analyses, to determine the practical feasibility of health interventions
recommended in the literature.


Strategic Tips for Interpreting a CEA
✓ Consider perspective. Which parties are incurring costs and which parties are
  receiving benefits? Many studies take a broad societal perspective; they are usually not
  written for an employer audience.
✓ Identify the strategies under comparison. Does the study compare different
  alternatives (treat using drug A vs. treat using drug B) or examine incremental
  changes in the same health intervention (screen every two years vs. screen every four
  years)?
✓ Be aware of the analytic horizon. When are costs incurred and when are benefits
  received? Most studies use a 3-5% annual discount rate to adjust both costs and
  benefits to a present value, but if a benefit is not received until 10 years after an
  intervention begins, this is important information to note.
✓ Analyze all stated assumptions. Are the assumptions built into the economic model
  clearly defined, and are they valid for employers?
✓ Examine the sensitivity analysis. How do differences in data inputs affect the
  outcome? Think how this relates to the health characteristics of your employee
  population.
✓ Understand all metrics. How did the author present the cost-effectiveness ratio?
  Most studies measure the costs of increased quality of life ($/quality adjusted life year
  gained), disability prevented ($/disability adjusted life year prevented) or of life saved
  ($/life year gained). A study that measures quality adjusted life years is called a
  cost-utility analysis, a specific type of CEA.
11 ISSUE   Brief       August 2004




      Sample Abstract


      The following abstract from a study published in the Journal of the American Medical
      Association shows that nicotine patch therapy, in conjunction with physician counseling,
      is a cost-effective approach to smoking cessation. This is an example of information in
      published CEAs that can support coverage decisions and justify health improvement
      programs.

      Cost-effectiveness of the transdermal nicotine patch as an adjunct to physicians' smoking
      cessation counseling

      K. Fiscella and P. Franks
      Primary Care Institute, Highland Hospital, Rochester, NY, USA.

      OBJECTIVE: To determine the incremental cost-effectiveness of the transdermal nicotine
      patch. DESIGN: Decision analytic model that evaluated the incremental cost-effectiveness
      of the addition of the nicotine patch to smoking cessation counseling. Costs were based
      on physician time and the retail cost of the nicotine patch, and benefits were based on
      quality-adjusted life years (QALYs) saved. PATIENTS: Male and female smokers aged 25
      to 69 years receiving primary care. INTERVENTION: Addition of the nicotine patch to
      physician-based smoking cessation counseling. MAIN OUTCOME MEASURE: Costs
      (1995 dollars) per QALYs saved discounted by 3% annually. RESULTS: The use of the
      patch produced one additional lifetime quitter at a cost of $7,332. The incremental cost
      effectiveness of the nicotine patch by age group ranged from $4,390 to $10,943 per
      QALY for men and $4,955 to $6,983 per QALY for women. A clinical strategy involving
      limiting prescription renewals to patients successfully abstaining for the first two weeks
      improved the cost-effectiveness of the patch by 25%. CONCLUSIONS: The findings
      provide support both for the routine use of the nicotine patch as an adjunct to physicians’
      smoking cessation counseling and for health insurance coverage of nicotine patch therapy.

      From JAMA 1996; 275: 1247-1251.
August 2004 ISSUE     Brief             12




Case Studies

Case Study 1 — A Large Manufacturing Company Redefines
Pharmacy Benefits

This global manufacturer of document management systems operates in more than 130
countries with more than 35,000 employees worldwide and 27,000 employees in the
United States. The company’s services include document management and mail security
products and systems.

In 2001, this company took a bold step to stem the rising costs of its health care benefits.
In analyzing where costs were the highest, the company found that those employees with
chronic conditions such as diabetes and asthma incurred the highest cost. Startlingly, they
found that many of these individuals did not refill their prescriptions properly because of
the high co-insurance price. Using predictive modeling to come to this conclusion and
hoping that increasing compliance would lower costs, the company’s medical director
restructured its pricing tiers for pharmaceuticals. The organization implemented a new
multi-tiered system in which generics and those drugs targeting chronic conditions such
as diabetes and asthma (including prescriptions for inhalers and insulin) would require co-
pays as low as 10% of the total cost.

After implementing this new pricing system at the end of 2001, the company realized
significant cost savings. Lower co-payments for the two chronic conditions had increased
compliance. Cost savings also came from fewer emergency room visits and hospital
admissions due to better personal disease management. Median medical costs for each
employee with diabetes fell 12%, and the company saved $1,000 per employee. For those
with asthma, median medical costs dropped 15% with a savings of $900 per person. The
company predicts savings estimated at $1 million in 2004 and even more in future years.
By using data-driven, total health strategy, a change that seemed costly has proven to be
cost-effective.
13 ISSUE   Brief         August 2004




  Case Study 2 — A Large Airline Reexamines Health Benefits Strategy

  This airline has more than 3,000 daily departures, flies to 38 states including the District
  of Columbia and 41 sites internationally, and employs more than 28,000 individuals. The
  organization recently faced several challenges:

  •   Negotiating with nine unions twice
  •   Filing for bankruptcy
  •   Outsourcing health care administration, which had been done internally
  •   Consolidating 23 health plans down to a single one

  During this period, many employees expressed discontent about plan changes, coverage
  decisions, and health care access. New executive leaders decided to fundamentally change
  health benefit strategy, including the use of cost-effectiveness analysis in plan design
  decisions. The company took the following actions:

  •   Requesting reports from vendors to assess health plan information
  •   Forming a collaborative union management group
  •   Establishing an internal plan performance group, including both finance and labor
      relations staff, to review health care data sets

  The airline is currently pursuing strategy that will facilitate positive health plan changes,
  made in collaboration with its unions and its health insurance carrier. Although it still
  faces serious financial challenges, the airline is now examining its health plan through
  data-driven discussions on whole health management and including cost-effectiveness
  analyses in health benefit strategy.
August 2004 ISSUE     Brief            14




Conclusion
Cost-effectiveness analyses provide quantitative support to managerial decision-making.
Budget requests and in-house proposals for health program change can be more
convincing with the addition of cost-effectiveness data. Asking vendors and consultants to
support their products and proposals with cost-effectiveness data assures managers they
are purchasing based on value. Organizations use these approaches and others because
they recognize that objective economic analyses such as CEA are sound corporate strategy.
15 ISSUE   Brief         August 2004




  Glossary of Cost-effectiveness Terms


  Many definitions are from Prevention Effectiveness: A Guide to Decision Analysis and
  Economic Evaluation. See references for more information.

  ✓ Agency for Healthcare Research and Quality (AHRQ): A federal agency with the
    mission to improve the quality, safety, efficiency, and effectiveness of health care for all
    Americans.

  ✓ Analytic horizon: The time period over which the costs and benefits of health
    outcomes that occur as the result of an intervention are considered.

  ✓ Annual discount rate: Adjustment made to the value of future costs and
    benefits to account for time preference and opportunity cost.

  ✓ Approach, access-oriented: Providing employees access to the health system through
    their benefits packages and managing costs by analyzing data for each covered benefit.

  ✓ Approach, system-oriented: Promoting employee health through an interrelated
    system of programs and benefits and managing costs with the knowledge that
    investment in one program or benefit may be offset by savings in others.

  ✓ Cost-effectiveness: The minimum cost for a given benefit, the maximum benefit for a
    given cost, or a balance of low costs and high benefits that has maximum utility.

  ✓ Cost-effectiveness analysis (CEA): An economic analysis in which all costs are
    related to a single, common effect, usually in terms of cost expended per outcome
    achieved.

  ✓ Cost-effectiveness ratio: The ratio of total costs of investment to total accrued
    benefits, in terms of both dollars and benefit value.

  ✓ Cost-utility analysis (CUA): A type of cost-effectiveness analysis in which benefits
    are expressed in terms of cost per QALY gained.

  ✓ Dominant choice: Choice with both lower costs and higher benefits than all other
    options.
August 2004 ISSUE     Brief            16




✓ Life year gained: An outcome measure that incorporates only duration of survival,
  not quality of life.

✓ Quality adjusted life year (QALY): A frequently used outcome measure that
  incorporates the quality and desirability of a health state with the duration of survival;
  quality of life is integrated with length of life using a multiplicative formula.

✓ Return on investment (ROI): The ratio of capital investment in dollars to accrued
  return in dollars.

✓ Sensitivity analysis: Mathematical calculations that isolate factors involved in an
  analysis to indicate the degree of influence each factor has on the outcome of the
  analysis.

✓ Societal perspective: Analytic view that includes all benefits of a program regardless
  of who receives them and all costs regardless of who pays them.
17 ISSUE   Brief        August 2004




  Web Resources


  ✓ Agency for Healthcare Research and Quality
    http://www.ahrq.gov/research/costeff.htm

     AHRQ is a leader in advancing the science of cost-effectiveness analysis in health care.
     This page explains current initiatives in this discipline, including the Research
     Initiative in Clinical Economics.

  ✓ United States Preventive Services Task Force
    http://www.ahrq.gov/clinic/uspstfix.htm

     USPSTF is an independent panel of experts in primary care and prevention that
     systematically reviews the evidence of and develops recommendations for clinical
     preventive services.

  ✓ National Health Service Centre for Reviews and Dissemination
    http://www.york.ac.uk/inst/crd/crddatabases.htm

     The United Kingdom’s National Health Service maintains databases of economic
     evaluations and health technology assessments at the University of York.

  ✓ Harvard Center for Risk Analysis CEA Registry
    http://www.hsph.harvard.edu/cearegistry/

     The Harvard School of Public Health maintained a reference list of cost-effectiveness
     analyses from 1976-2001. It does not include more current studies, but serves as a
     useful historical database.
August 2004 ISSUE      Brief            18




Print Resources


✓ Haddix A., Teutsch S., Corso P. Prevention Effectiveness: A Guide to Decision
  Analysis and Economic Evaluation. New York: Oxford University Press, 2003.
   Officials from AHRQ and CDC collaborated with leading academics on this text. It
   gives in-depth explanations of cost-effectiveness analysis beginning with theory and
   concluding with application.

✓ Gold M. R., Siegel J. E., Russell L. B., Weinstein M.C. Cost-Effectiveness in Health
  and Medicine. New York: Oxford University Press, 1996.

   This report details the recommendations of the Panel on Cost-Effectiveness in Health
   in Medicine, a committee of researchers convened by the United States Public Health
   Service to establish guidelines for analyses. The findings of the Panel are also outlined
   in three articles in the Journal of the American Medical Association (JAMA 1996;
   276: 1172-1177, 1253-1258, and 1339-1341).

✓ Schoenbaum M., Unutzer J., Sherbourne C., Duan N., Rubenstein L.V., Miranda J.,
  Meredith L.S., Carney M.F. and Wells K. “The Cost-effectiveness of Practice-Initiated
  Quality Improvement for Depression: Results from a Randomized, Controlled Trial,”
  JAMA 2001; 286: 1325-1330.

   Dr. Schoenbaum, a speaker at the May 2004 web event, conducted an analysis of a
   quality improvement program for depression treatment (see Page 3, Table 2 ). His
   publication demonstrates the usefulness of cost-effectiveness analysis as an evaluative
   tool.

✓ Neumann P.J. “Why Don’t Americans Use Cost-Effectiveness Analysis?” American
  Journal of Managed Care 2004; 10: 308-312.

   Neumann presents a short editorial explaining resistance to cost-effectiveness analysis
   in the United States. He surmises the positions of different stakeholder groups toward
   CEA and offers thoughts to help decision makers better use CEA in the future.
19 ISSUE   Brief       August 2004




  References


  ✓ Fuhrmans V. “A Radical Prescription.” Wall Street Journal, May 10, 2004.

  ✓ Haddix A. et al. “Prevention Effectiveness: A Guide to Decision Analysis and
    Economic Evaluation.” New York, NY: Oxford University Press, 2003.

  ✓ Fiscella K. and Franks P. “Cost-effectiveness of the transdermal nicotine patch as an
    adjunct to physicians’ smoking cessation counseling.” JAMA 1996; 275: 1247-1251.
Center for
          Prevention ISSUE
          and Health August 2004
                                         Brief
            Services Cost-Effectiveness Analysis:
                      An Employer Decision Support Tool



Written by:
Ian Dixon and Andrew Lundeen, National Business Group on Health
About the Center for Prevention and Health Services (CPHS)
The Center houses the Business Group’s projects and resources that relate to the delive ry
of preventive and other health services through employe r - s p o n s o re health plans and work s i t e
                                                                         d
programs. Through the Center, employers can find practical toolkits to address pre ve n t i ve
health and health promotion issues at the worksite. Em p l oyers will find current information
and recommendations from federal agencies and professional associations, model programs
from other employers, and the latest clinical and health services research results. In addition,
the Center provides opportunities for employer participation in teleconferences and in-person
solutions workshops. Currently, the Center has initiatives in racial and ethnic disparities in health
and health care, terrorism and public health emergency preparedness, maternal and child health,
preventive services, health services research and quality, health and work performance, benefit
design, and wellness programs.
For more information, visit http://www.businessgrouphealth.org/pre vention/index.cfm
or contact Ron Finch, EdD, Director, at finch@businessgrouphealth.org.

About the National Business Group on Health

The National Business Group on Health, formerly the Washington Business Group on Health,
is the national voice of large employers dedicated to finding innovative and forward-thinking
solutions to the nation’s most important health care issues. The Business Group represents over
200 members, primarily Fortune 500 companies and large public sector employers, who provide
health coverage for approximately 50 million U.S. workers, retirees, and their families. The
Business Group fosters the development of a quality health care delivery system and treatments
based on scientific evidence of effectiveness. The Business Group works with other organizations
to promote patient safety and expand the use of technology assessment to ensure access to
superior new technology and the elimination of ineffective technology.

Helen Darling, President
National Business Group on Health
50 F Street NW, Suite 600 • Washington DC 20001
Phone (202) 628-9320 • Fax (202) 628-9244 • www.businessgrouphealth.org

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Cost Effectiveness Analysis in Health economics

  • 1. Center for Prevention Brief and Health Services ISSUE August 2004 Cost-Effectiveness Analysis: An Employer Decision Support Tool This issue brief summarizes information presented at Cost-Effectiveness Analysis: An Employer Decision Support Tool, a web-based seminar at the National Business Group on Health sponsored by the Agency for Healthcare Research and Quality. Statistics and figures that are not annotated with a source were presented by the speakers. A glossary of italicized terms and a bibliography of additional cost-effectiveness resources are listed at the end of the brief. Introduction Table of Contents: Large employers face a challenging future in Introduction 1 managing health care benefits. Managers have many Cost-Effectiveness Analysis Basics 2 program and coverage options, but are limited by Why Employers Use CEA 3 budget constraints and data availability. Common Applications 4 Traditionally, decision-makers have used return on S t r ategic Implicat i o n s 6 Practical Examples 9 investment calculations to help guide their S t r ategic Tips for Interpreting CEA 10 investment choices, but they can also consider Sample Abstract 11 another tool — cost-effectiveness analysis. Case Studies 12 Conclusion 14 Cost-effectiveness analysis (CEA) is a method of Glossary 15 Resources 17 financial evaluation that has gained prominence References 19 within academic and policy communities in the last 20 years. But this methodology can also have business applications as a decision support tool. This issue brief explains cost-effectiveness analysis, outlines its usefulness to employers, demonstrates how cost-effectiveness relates to corporate strategy, and gives examples of its applications in health benefits decisions.
  • 2. August 2004 ISSUE Brief 2 Cost-Effectiveness Analysis Basics Cost-effectiveness analysis is a specific type of economic analysis in which all costs are related to a single, common effect. Decision makers can use it to compare different resource allocation options in like terms. A general misconception is that CEA is merely a means of finding the least expensive alternative or getting the “most bang for the buck.” In reality, CEA is a comparison tool; it will not always indicate a clear choice, but it will evaluate options quantitatively and objectively based on a defined model. CEA was designed to evaluate health care interventions, but the methodology can be used for non- health economic applications as well. It can compare any resource allocation with measurable outcomes to any other resource allocation with measurable outcomes. Cost-effectiveness analysis, or Conducting, Evaluating, and CEA, is a comparison tool to help Using Analyses evaluate choices. It will not always indicate a clear choice, Increasing numbers of analyses are but it will evaluate options conducted in academia or research quantitatively based on a defined organizations and published in model. For managers, CEA peer-reviewed journals. Government provides peer-reviewed evidence organizations use analyses to help for decision support. shape public policy. Health insurers use CEAs to determine which kinds of health interventions to cover. There is a growing body of work that quantitatively compares the health returned on different interventions employers cover in their benefits packages. As employers are increasingly asking providers to practice evidence-based medicine, they can direct this trend by evaluating and acting on evidence, or by holding health plans and consultants accountable for evaluation and action.
  • 3. 3 ISSUE Brief August 2004 Cost-Effectiveness Ratio The cost-effectiveness ratio is simply the sum of all benefits divided by the sum of all costs. This is comparable to a return on investment calculation; however, the benefits are not measured in terms of just dollars, but in a ratio that incorporates both health outcomes and dollars. Since healthier employees are more productive, improved outcomes actually do translate into dollars. But it is important to keep these values separate, so a decision maker can understand what kind of health benefit is returned on the investment. For instance, three investment choices could have cost-effectiveness ratios of Cost-Effectiveness Ratio = $10,000/premature birth avoided, $20,000/workplace (All benefits) injury prevented, or $30,000/life year gained. The decision maker must then choose the health intervention (All costs) that is right in terms of budget and population health goals. CEAs compare several program strategies and then rank them by of cost-effectiveness ratios. An analysis of two screening interventions might show you that one costs $10,000/life year gained while the other costs $40,000/life year gained. The first intervention requires monthly screening and the second requires biannual screening. Realizing that compliance is a greater problem with monthly screening, the decision maker would have to implement the most appropriate coverage strategy for the population in question. Sometimes, the analysis compares to baseline options such as “do nothing” or “usual care.” Both are valid strategic options. Why Employers Use CEA Cost-effectiveness analysis: ✓ Supports objective decision making: Decision makers can consider options in a comparable and objective way that provides support for the final decision. ✓ Brings clarity to data sources and outcomes: CEA evaluates options in similar terms to avoid “comparing apples to oranges.”
  • 4. August 2004 ISSUE Brief 4 ✓ Allows for strategic review of organizations: CEA might justify some operational centers operating at a loss to increase overall return on investment, employee health, or both. ✓ Can be used in a host of operational and benefits areas including: • Screening coverage • Pharmacy • Strategic Planning • Labor Relations • Disease Management • Disability Management • Wellness and Prevention Programs ✓ Presents evidence that can help gain support for changes in benefits plans or employer-sponsored health programs. Common Applications Evaluating Program Options In the case of health screening, it is often difficult to determine the most cost-effective frequency. Too frequent screening has high cost and possibly limited health benefits, while too infrequent screening has low cost, but poor health outcomes. Determining appropriate screening frequencies is a useful application of cost-effectiveness analysis. The following table taken from an analysis on cervical cancer screening shows that life years are saved at a relatively low cost in the first comparison (screening versus no screening), but at a very high cost in the second comparison (the marginal cost and benefit of decreasing the interval between screenings). Typically, an intervention that costs less than $30,000/life year gained is considered cost-effective medicine. Based on this analysis, cervical cancer screening every four years is a relatively cost-effective benefit to cover. It is certainly more cost-effective than screening every three years.
  • 5. 5 ISSUE Brief August 2004 Table 1: Example Data from an Analysis of Cervical Cancer Screening Frequency Screen every four years Screen every three vs. no screening years vs. screen every four years Life expectancy increase, days 93.8 1.6 Life expectancy increase, days (discounted 5%)* 9.5 0.2 Cost increase, dollars (discounted 5%) $264 $91 Cost per life year gained $10,101 $184,528 Source: E d dy D.M. “Screening for Cervical Cancer,” Annals of Internal Medicine 1990; 113: 214-226. * Annual discount rat e adjust future costs and benefits to account for time preference and opportunity cost. Justifying Program Implementation When building a case to justify the use of funds, strong data is often compelling evidence. Cost-effectiveness analyses can be used to support qualitative arguments for health interventions. The following table examines a depression treatment improvement program. Treatment facilities in the study were offered training for practice leaders and nurses, enhanced educational and assessment resources, and trained psychotherapists for patient follow-ups. Not only was the intervention relatively cost-effective, but it also increased attendance in workers suffering from depression. Table 2: Example Data from an Analysis of a Depression Treatment Improvement Program Quality improvement program vs. usual care Quality-adjusted life year increase 0.0226 Cost increase $485 Cost per quality adjusted life year $21,460 Days of employment increase 20.9 Source: Schoenbaum M. et al. “The Cost-effectiveness of Practice-Initiated Quality Improvement for Depression: Results from a Randomized, Controlled Trial,” JAMA 2001; 286: 1325-1330.
  • 6. August 2004 ISSUE Brief 6 Cost-effectiveness analysis can be a valuable source of information and data for employers. Most employers are not in the business of conducting analyses; however, it is reasonable to expect carriers to rationalize and explain different coverage options in terms of cost- effectiveness. Strategic Implications A System View Because cost-effectiveness analysis examines a comprehensive set of costs and outcomes, it is important to avoid narrow strategy that only considers implication for individual department programs or cost centers. Managers can examine all parts of the health benefits system to determine if financial losses in one area are recouped in another. For example, dollars spent in richer benefit reimbursement might increase utilization and avoid future costs of treatment. The diagram below presents a system view of employer-sponsored health care. INPUTS • Diverse Workforce • Work Environment • HR & Benefits • Vendors & Providers Health Symptoms Diagnosis & Benefit Behavior & Disease Treatment Reimbursement OUTPUTS • Health Stat u s • Productivity • Health Care Costs • Retention • Disability/Absenteeism • Presenteeism Source: Michael Thompson, PricewaterhouseCoopers
  • 7. 7 ISSUE Brief August 2004 Employers can use cost-effectiveness analysis to review each system component and choose the best strategy to optimize utilization, improve outcomes, and encourage healthier and more beneficial lifestyle choices. Strategic Readiness Unconventional methods like cost-effectiveness analysis are not an ideal fit for all organizations. Every company that provides health benefits has a different strategy for plan design and analysis. In some organizations, an attempt to incorporate cost- effectiveness analysis into decision making might be resisted or rejected altogether. To avoid such a misstep, assessment of corporate culture is necessary. The diagram below shows health care strategy as a continuum. Organizations that are more access-oriented analyze specific health care costs and delegate cost reduction responsibility to their carriers. Goals focus on controlling costs so that employers can continue to offer health care access through employee benefits. Organizations that are more system-oriented involve employees, employers, and health plans in dialogue about whole health management. Shared goals focus on increasing health and changing utilization patterns to control future costs. Access System Oriented Health Care Strategy Oriented Approach Approach Aware & E n g age & Leadership Inactive Enable Employee Share Culture Benefit Responsibility Health Care Health & Access & Cost Focus Performance Delegated Integrated & Accountability Health Plans Optimized Source: Michael Thompson, PricewaterhouseCoopers
  • 8. August 2004 ISSUE Brief 8 To assess where large employers believe they lie on this continuum, a number of benefits, health, and human resources professionals rated their organizations on a scale from 1 (mostly access-oriented) to 5 (mostly system-oriented) for the four component areas as well as overall approach.
  • 9. 9 ISSUE Brief August 2004 Practical Examples Pharmaceutical Formularies Employers can use CEA to compare specific drugs on their formularies or evaluate the cost-effectiveness of their entire pharmaceutical benefits packages. In comparing specific drugs, such as high-cost statins and beta-blockers, benefits managers address not only cost differences between brand name and generic, but disparities in effectiveness as well. This might include examining effectiveness per dose cost. For example, a particular statin may be the least expensive option per dose, but comparing it to other options in terms of cost and ability to reduce LDL levels may prove it is a less cost-effective choice (see Table 3). In analyzing an entire pharmacy program, employers determine costs for particular drugs in terms of tiers and responsibility. The recent trend has been for employers to shift more of the costs of medications to employees through higher co-pays or co-insurance, but this may not always be the most cost-effective long-term solution. Abandoning this strategy may create a financial loss on some prescriptions, but overall cost savings could be substantial if absenteeism, presenteeism, and disability are reduced in the process. Companies might also consider how they will price brand name drugs versus generics, especially for medications that have proven to be similar in safety and effectiveness. Table 3: Example Data from a Comparison of Six Statins Daily Dose (% LDL reduction/dose cost) Statin 5 mg 10 mg 20 mg 40 mg 80 mg Statin A N/A 39%/$2.04 43%/$3.07 50%/$3.07 60%/$3.07 Statin B N/A N/A 22%/$1.56 25%/$1.56 35%/$1.97 Statin C N/A 21%/$0.96 27%/$1.11 31%/$1.97 N/A Statin D N/A 22%/$2.50 32%/$2.52 34%/$3.07 37%/$3.76 Statin E 45%/$2.22 52%/$2.22 55%/$2.22 63%/$2.22 N/A Statin F 26%/$1.63 30%/$2.18 30%/$2.18 41%/$3.72 47%/$3.73 Source: Michael Jacobs, Mercer Human Resource Consulting If decision makers were only looking for the lowest cost alternatives, they might select 10mg of statin C. However, 40mg of statin E is the most cost-effective option. This dosage has the highest LDL reduction for the cost associated with it. Benefit managers can consider this information in making formulary decisions; however, this may not be the most favorable option when factors such as employee health characteristics, unions, and other issues weigh into the choice.
  • 10. August 2004 ISSUE Brief 10 Disease Management and Treatment Cost-effectiveness analysis is a useful tool in developing and evaluating disease management and treatment programs. It allows employers to determine objectively what services to cover, for which populations, and how often. Employers, providers, and insurers will normally seek the dominant choice — that choice which has lower costs and better outcomes than other choices in the same situation. Often, lower costs may be realized at the expense of outcomes, or better outcomes achieved at unacceptable costs. In such cases, cost-effectiveness analysis can compare options and lead to smarter choices. Employers and health plans can also use CEA to determine limits on coverage — for what age, for which populations, how often, and other restrictions. A helpful reference for such decisions may be the United States Preventive Services Task Force recommendations for clinical services. The Task Force critically examines published research, including cost- effectiveness analyses, to determine the practical feasibility of health interventions recommended in the literature. Strategic Tips for Interpreting a CEA ✓ Consider perspective. Which parties are incurring costs and which parties are receiving benefits? Many studies take a broad societal perspective; they are usually not written for an employer audience. ✓ Identify the strategies under comparison. Does the study compare different alternatives (treat using drug A vs. treat using drug B) or examine incremental changes in the same health intervention (screen every two years vs. screen every four years)? ✓ Be aware of the analytic horizon. When are costs incurred and when are benefits received? Most studies use a 3-5% annual discount rate to adjust both costs and benefits to a present value, but if a benefit is not received until 10 years after an intervention begins, this is important information to note. ✓ Analyze all stated assumptions. Are the assumptions built into the economic model clearly defined, and are they valid for employers? ✓ Examine the sensitivity analysis. How do differences in data inputs affect the outcome? Think how this relates to the health characteristics of your employee population. ✓ Understand all metrics. How did the author present the cost-effectiveness ratio? Most studies measure the costs of increased quality of life ($/quality adjusted life year gained), disability prevented ($/disability adjusted life year prevented) or of life saved ($/life year gained). A study that measures quality adjusted life years is called a cost-utility analysis, a specific type of CEA.
  • 11. 11 ISSUE Brief August 2004 Sample Abstract The following abstract from a study published in the Journal of the American Medical Association shows that nicotine patch therapy, in conjunction with physician counseling, is a cost-effective approach to smoking cessation. This is an example of information in published CEAs that can support coverage decisions and justify health improvement programs. Cost-effectiveness of the transdermal nicotine patch as an adjunct to physicians' smoking cessation counseling K. Fiscella and P. Franks Primary Care Institute, Highland Hospital, Rochester, NY, USA. OBJECTIVE: To determine the incremental cost-effectiveness of the transdermal nicotine patch. DESIGN: Decision analytic model that evaluated the incremental cost-effectiveness of the addition of the nicotine patch to smoking cessation counseling. Costs were based on physician time and the retail cost of the nicotine patch, and benefits were based on quality-adjusted life years (QALYs) saved. PATIENTS: Male and female smokers aged 25 to 69 years receiving primary care. INTERVENTION: Addition of the nicotine patch to physician-based smoking cessation counseling. MAIN OUTCOME MEASURE: Costs (1995 dollars) per QALYs saved discounted by 3% annually. RESULTS: The use of the patch produced one additional lifetime quitter at a cost of $7,332. The incremental cost effectiveness of the nicotine patch by age group ranged from $4,390 to $10,943 per QALY for men and $4,955 to $6,983 per QALY for women. A clinical strategy involving limiting prescription renewals to patients successfully abstaining for the first two weeks improved the cost-effectiveness of the patch by 25%. CONCLUSIONS: The findings provide support both for the routine use of the nicotine patch as an adjunct to physicians’ smoking cessation counseling and for health insurance coverage of nicotine patch therapy. From JAMA 1996; 275: 1247-1251.
  • 12. August 2004 ISSUE Brief 12 Case Studies Case Study 1 — A Large Manufacturing Company Redefines Pharmacy Benefits This global manufacturer of document management systems operates in more than 130 countries with more than 35,000 employees worldwide and 27,000 employees in the United States. The company’s services include document management and mail security products and systems. In 2001, this company took a bold step to stem the rising costs of its health care benefits. In analyzing where costs were the highest, the company found that those employees with chronic conditions such as diabetes and asthma incurred the highest cost. Startlingly, they found that many of these individuals did not refill their prescriptions properly because of the high co-insurance price. Using predictive modeling to come to this conclusion and hoping that increasing compliance would lower costs, the company’s medical director restructured its pricing tiers for pharmaceuticals. The organization implemented a new multi-tiered system in which generics and those drugs targeting chronic conditions such as diabetes and asthma (including prescriptions for inhalers and insulin) would require co- pays as low as 10% of the total cost. After implementing this new pricing system at the end of 2001, the company realized significant cost savings. Lower co-payments for the two chronic conditions had increased compliance. Cost savings also came from fewer emergency room visits and hospital admissions due to better personal disease management. Median medical costs for each employee with diabetes fell 12%, and the company saved $1,000 per employee. For those with asthma, median medical costs dropped 15% with a savings of $900 per person. The company predicts savings estimated at $1 million in 2004 and even more in future years. By using data-driven, total health strategy, a change that seemed costly has proven to be cost-effective.
  • 13. 13 ISSUE Brief August 2004 Case Study 2 — A Large Airline Reexamines Health Benefits Strategy This airline has more than 3,000 daily departures, flies to 38 states including the District of Columbia and 41 sites internationally, and employs more than 28,000 individuals. The organization recently faced several challenges: • Negotiating with nine unions twice • Filing for bankruptcy • Outsourcing health care administration, which had been done internally • Consolidating 23 health plans down to a single one During this period, many employees expressed discontent about plan changes, coverage decisions, and health care access. New executive leaders decided to fundamentally change health benefit strategy, including the use of cost-effectiveness analysis in plan design decisions. The company took the following actions: • Requesting reports from vendors to assess health plan information • Forming a collaborative union management group • Establishing an internal plan performance group, including both finance and labor relations staff, to review health care data sets The airline is currently pursuing strategy that will facilitate positive health plan changes, made in collaboration with its unions and its health insurance carrier. Although it still faces serious financial challenges, the airline is now examining its health plan through data-driven discussions on whole health management and including cost-effectiveness analyses in health benefit strategy.
  • 14. August 2004 ISSUE Brief 14 Conclusion Cost-effectiveness analyses provide quantitative support to managerial decision-making. Budget requests and in-house proposals for health program change can be more convincing with the addition of cost-effectiveness data. Asking vendors and consultants to support their products and proposals with cost-effectiveness data assures managers they are purchasing based on value. Organizations use these approaches and others because they recognize that objective economic analyses such as CEA are sound corporate strategy.
  • 15. 15 ISSUE Brief August 2004 Glossary of Cost-effectiveness Terms Many definitions are from Prevention Effectiveness: A Guide to Decision Analysis and Economic Evaluation. See references for more information. ✓ Agency for Healthcare Research and Quality (AHRQ): A federal agency with the mission to improve the quality, safety, efficiency, and effectiveness of health care for all Americans. ✓ Analytic horizon: The time period over which the costs and benefits of health outcomes that occur as the result of an intervention are considered. ✓ Annual discount rate: Adjustment made to the value of future costs and benefits to account for time preference and opportunity cost. ✓ Approach, access-oriented: Providing employees access to the health system through their benefits packages and managing costs by analyzing data for each covered benefit. ✓ Approach, system-oriented: Promoting employee health through an interrelated system of programs and benefits and managing costs with the knowledge that investment in one program or benefit may be offset by savings in others. ✓ Cost-effectiveness: The minimum cost for a given benefit, the maximum benefit for a given cost, or a balance of low costs and high benefits that has maximum utility. ✓ Cost-effectiveness analysis (CEA): An economic analysis in which all costs are related to a single, common effect, usually in terms of cost expended per outcome achieved. ✓ Cost-effectiveness ratio: The ratio of total costs of investment to total accrued benefits, in terms of both dollars and benefit value. ✓ Cost-utility analysis (CUA): A type of cost-effectiveness analysis in which benefits are expressed in terms of cost per QALY gained. ✓ Dominant choice: Choice with both lower costs and higher benefits than all other options.
  • 16. August 2004 ISSUE Brief 16 ✓ Life year gained: An outcome measure that incorporates only duration of survival, not quality of life. ✓ Quality adjusted life year (QALY): A frequently used outcome measure that incorporates the quality and desirability of a health state with the duration of survival; quality of life is integrated with length of life using a multiplicative formula. ✓ Return on investment (ROI): The ratio of capital investment in dollars to accrued return in dollars. ✓ Sensitivity analysis: Mathematical calculations that isolate factors involved in an analysis to indicate the degree of influence each factor has on the outcome of the analysis. ✓ Societal perspective: Analytic view that includes all benefits of a program regardless of who receives them and all costs regardless of who pays them.
  • 17. 17 ISSUE Brief August 2004 Web Resources ✓ Agency for Healthcare Research and Quality http://www.ahrq.gov/research/costeff.htm AHRQ is a leader in advancing the science of cost-effectiveness analysis in health care. This page explains current initiatives in this discipline, including the Research Initiative in Clinical Economics. ✓ United States Preventive Services Task Force http://www.ahrq.gov/clinic/uspstfix.htm USPSTF is an independent panel of experts in primary care and prevention that systematically reviews the evidence of and develops recommendations for clinical preventive services. ✓ National Health Service Centre for Reviews and Dissemination http://www.york.ac.uk/inst/crd/crddatabases.htm The United Kingdom’s National Health Service maintains databases of economic evaluations and health technology assessments at the University of York. ✓ Harvard Center for Risk Analysis CEA Registry http://www.hsph.harvard.edu/cearegistry/ The Harvard School of Public Health maintained a reference list of cost-effectiveness analyses from 1976-2001. It does not include more current studies, but serves as a useful historical database.
  • 18. August 2004 ISSUE Brief 18 Print Resources ✓ Haddix A., Teutsch S., Corso P. Prevention Effectiveness: A Guide to Decision Analysis and Economic Evaluation. New York: Oxford University Press, 2003. Officials from AHRQ and CDC collaborated with leading academics on this text. It gives in-depth explanations of cost-effectiveness analysis beginning with theory and concluding with application. ✓ Gold M. R., Siegel J. E., Russell L. B., Weinstein M.C. Cost-Effectiveness in Health and Medicine. New York: Oxford University Press, 1996. This report details the recommendations of the Panel on Cost-Effectiveness in Health in Medicine, a committee of researchers convened by the United States Public Health Service to establish guidelines for analyses. The findings of the Panel are also outlined in three articles in the Journal of the American Medical Association (JAMA 1996; 276: 1172-1177, 1253-1258, and 1339-1341). ✓ Schoenbaum M., Unutzer J., Sherbourne C., Duan N., Rubenstein L.V., Miranda J., Meredith L.S., Carney M.F. and Wells K. “The Cost-effectiveness of Practice-Initiated Quality Improvement for Depression: Results from a Randomized, Controlled Trial,” JAMA 2001; 286: 1325-1330. Dr. Schoenbaum, a speaker at the May 2004 web event, conducted an analysis of a quality improvement program for depression treatment (see Page 3, Table 2 ). His publication demonstrates the usefulness of cost-effectiveness analysis as an evaluative tool. ✓ Neumann P.J. “Why Don’t Americans Use Cost-Effectiveness Analysis?” American Journal of Managed Care 2004; 10: 308-312. Neumann presents a short editorial explaining resistance to cost-effectiveness analysis in the United States. He surmises the positions of different stakeholder groups toward CEA and offers thoughts to help decision makers better use CEA in the future.
  • 19. 19 ISSUE Brief August 2004 References ✓ Fuhrmans V. “A Radical Prescription.” Wall Street Journal, May 10, 2004. ✓ Haddix A. et al. “Prevention Effectiveness: A Guide to Decision Analysis and Economic Evaluation.” New York, NY: Oxford University Press, 2003. ✓ Fiscella K. and Franks P. “Cost-effectiveness of the transdermal nicotine patch as an adjunct to physicians’ smoking cessation counseling.” JAMA 1996; 275: 1247-1251.
  • 20. Center for Prevention ISSUE and Health August 2004 Brief Services Cost-Effectiveness Analysis: An Employer Decision Support Tool Written by: Ian Dixon and Andrew Lundeen, National Business Group on Health About the Center for Prevention and Health Services (CPHS) The Center houses the Business Group’s projects and resources that relate to the delive ry of preventive and other health services through employe r - s p o n s o re health plans and work s i t e d programs. Through the Center, employers can find practical toolkits to address pre ve n t i ve health and health promotion issues at the worksite. Em p l oyers will find current information and recommendations from federal agencies and professional associations, model programs from other employers, and the latest clinical and health services research results. In addition, the Center provides opportunities for employer participation in teleconferences and in-person solutions workshops. Currently, the Center has initiatives in racial and ethnic disparities in health and health care, terrorism and public health emergency preparedness, maternal and child health, preventive services, health services research and quality, health and work performance, benefit design, and wellness programs. For more information, visit http://www.businessgrouphealth.org/pre vention/index.cfm or contact Ron Finch, EdD, Director, at finch@businessgrouphealth.org. About the National Business Group on Health The National Business Group on Health, formerly the Washington Business Group on Health, is the national voice of large employers dedicated to finding innovative and forward-thinking solutions to the nation’s most important health care issues. The Business Group represents over 200 members, primarily Fortune 500 companies and large public sector employers, who provide health coverage for approximately 50 million U.S. workers, retirees, and their families. The Business Group fosters the development of a quality health care delivery system and treatments based on scientific evidence of effectiveness. The Business Group works with other organizations to promote patient safety and expand the use of technology assessment to ensure access to superior new technology and the elimination of ineffective technology. Helen Darling, President National Business Group on Health 50 F Street NW, Suite 600 • Washington DC 20001 Phone (202) 628-9320 • Fax (202) 628-9244 • www.businessgrouphealth.org