Bryan Stirling, Sofaer Shoshanna, Siegelberg Taryn, Gold Marthe
University of British Columbia, Canada.
Health Econ Policy Law. 2009 Oct;4(Pt 4):425-43. doi: 10.1017/S1744133109004885. Epub 2009 Feb 9.
Cost-effectiveness analysis (CEA) is a powerful analytic tool for assessing the value of health care interventions but it is a method used sparingly in the US. Despite its growing acceptance internationally and its endorsement in the academic literature, most policy analysts have assumed that US decision makers will resist using CEA to inform coverage decisions. This study sought to clarify the extent to which CEA is understood and accepted by US decision makers, including regulators, private and public insurers, and purchasers, and to identify their points of difficulty with its use. We conducted half-day workshops with a sample of six California-based health care organizations that spanned a range of public and private perspectives regarding coverage of health care services. Each workshop included an overview of CEA methods, a priority-setting exercise that asked participants (acting as 'social decision makers') to rank condition treatment pairs prior to and following provision of cost-effectiveness information; and a facilitated discussion of obstacles and opportunities for using CEA in their own organizations. Pre and post-questionnaires inquired as to obstacles toward implementing CEA, attitudes toward rationing, and views on the use of CEA in Medicare and in private insurance coverage decision-making. In post-workshop surveys major obstacles identified included: fears of litigation, concerns about the quality and accuracy of studies that were commercially sponsored, and failure of CEAs to address shorter horizon cost implications. Over 90% of participants felt that CEA should be used as an input to Medicare coverage decisions and 75% supported its use in such decisions by private insurance plans. Despite the wide acceptance of CEA, at the conclusion of the workshop, 40% of the sample remained uncomfortable with support of 'rationing' per se. We suggest that how cost-effectiveness analysis is framed will have important implications for its acceptability to US decision makers.
成本效益分析（CEA）是评估医疗保健干预措施价值的一种强大分析工具，但在美国却很少使用。尽管它在国际上越来越被接受，并且在学术文献中也得到了认可，但大多数政策分析师认为美国决策者会抵制使用CEA来为保险覆盖范围决策提供信息。本研究旨在阐明美国决策者（包括监管机构、私人和公共保险公司以及购买者）对CEA的理解和接受程度，并确定他们在使用CEA时遇到的困难点。我们对六个位于加利福尼亚州的医疗保健组织进行了为期半天的研讨会，这些组织涵盖了关于医疗保健服务覆盖范围的一系列公共和私人观点。每个研讨会都包括CEA方法概述、一个优先排序练习，要求参与者（作为“社会决策者”）在提供成本效益信息之前和之后对疾病治疗对进行排序；以及一场关于在其各自组织中使用CEA的障碍和机会的引导式讨论。会前和会后问卷询问了实施CEA的障碍、对配给的态度以及对CEA在医疗保险和私人保险覆盖范围决策中的使用看法。在会后调查中，确定的主要障碍包括：对诉讼的担忧、对商业赞助研究的质量和准确性的关注，以及CEA未能解决短期成本影响。超过90%的参与者认为CEA应用作医疗保险覆盖范围决策的一项参考依据，75%的参与者支持其在私人保险计划的此类决策中使用。尽管CEA被广泛接受，但在研讨会结束时，40%的样本仍然对支持“配给”本身感到不安。我们认为成本效益分析的框架方式将对其在美国决策者中的可接受性产生重要影响。
