Pennsylvania State University, University Park, Pennsylvania (D.J.V., H.A.).
University of York, York, United Kingdom (J.L.).
Ann Intern Med. 2021 Jan;174(1):25-32. doi: 10.7326/M20-1392. Epub 2020 Nov 3.
BACKGROUND: Cost-effectiveness analysis is an important tool for informing treatment coverage and pricing decisions, yet no consensus exists about what threshold for the incremental cost-effectiveness ratio (ICER) in dollars per quality-adjusted life-year (QALY) gained indicates whether treatments are likely to be cost-effective in the United States. OBJECTIVE: To estimate a U.S. cost-effectiveness threshold based on health opportunity costs. DESIGN: Simulation of short-term mortality and morbidity attributable to persons dropping health insurance due to increased health care expenditures passed though as premium increases. Model inputs came from demographic data and the literature; 95% uncertainty intervals (UIs) were constructed. SETTING: Population-based. PARTICIPANTS: Simulated cohort of 100 000 individuals from the U.S. population with direct-purchase private health insurance. MEASUREMENTS: Number of persons dropping insurance coverage, number of additional deaths, and QALYs lost from increased mortality and morbidity, all per increase of $10 000 000 (2019 U.S. dollars) in population treatment cost. RESULTS: Per $10 000 000 increase in health care expenditures, 1860 persons (95% UI, 1080 to 2840 persons) were simulated to become uninsured, causing 5 deaths (UI, 3 to 11 deaths), 81 QALYs (UI, 40 to 170 QALYs) lost due to death, and 15 QALYs (UI, 6 to 32 QALYs) lost due to illness; this implies a cost-effectiveness threshold of $104 000 per QALY (UI, $51 000 to $209 000 per QALY) in 2019 U.S. dollars. Given available evidence, there is about 14% probability that the threshold exceeds $150 000 per QALY and about 48% probability that it lies below $100 000 per QALY. LIMITATIONS: Estimates were sensitive to inputs, most notably the effects of losing insurance on mortality and of premium increases on becoming uninsured. Health opportunity costs may vary by population. Nonhealth opportunity costs were excluded. CONCLUSION: Given current evidence, treatments with ICERs above the range $100 000 to $150 000 per QALY are unlikely to be cost-effective in the United States. PRIMARY FUNDING SOURCE: None.
背景：成本效益分析是为治疗提供覆盖范围和定价决策的重要工具，但对于增量成本效益比（ICER）每增加一个质量调整生命年（QALY）的美元阈值表示治疗在美国是否具有成本效益，尚无共识。 目的：根据健康机会成本来估计美国的成本效益阈值。 设计：由于医疗保健支出增加而导致的医疗保险退保导致的短期死亡率和发病率的模拟。模型输入来自人口统计数据和文献；构建了 95%的置信区间（UI）。 设置：基于人群。 参与者：来自具有直接购买私人医疗保险的美国人群的 100000 人的模拟队列。 测量：由于死亡率和发病率增加而导致的保险范围下降人数、额外死亡人数和 QALY 损失，所有这些都是由于每增加 1000 万美元（2019 年美元）的人群治疗费用而产生的。 结果：每增加 1000 万美元的医疗保健支出，模拟有 1860 人（95%UI，1080 至 2840 人）失去保险，导致 5 人死亡（UI，3 至 11 人死亡），81 个 QALY（UI，40 至 170 个 QALY）由于死亡而损失，15 个 QALY（UI，6 至 32 个 QALY）由于疾病而损失；这意味着 2019 年美元的每 QALY 成本效益阈值为 104000 美元（UI，51000 至 209000 美元/QALY）。根据现有证据，阈值超过每 QALY 150000 美元的可能性约为 14%，低于每 QALY 100000 美元的可能性约为 48%。 局限性：估计值对投入敏感，尤其是失去保险对死亡率的影响以及保费增加对失去保险的影响。健康机会成本可能因人群而异。排除了非健康机会成本。 结论：根据现有证据，ICER 高于每 QALY 100000 至 150000 美元的治疗方法在美国不太可能具有成本效益。 主要资金来源：无。
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