HMGT 435 WEEK 7 DISC 7

CHAPTER

355

COMPARATIVE EFFECTIVENESS RESEARCH

A s part of the $787 billion stimulus bill passed in 2010, Congress allocated $1.1 billion for comparative effectiveness research (CER). The Afford- able Care Act (ACA) of 2010 included an additional $3 billion for

studies to compare the effectiveness of different treatments for the same illness. The different treatments include drugs, medical devices, surgery, and other ways of treating a specific medical condition (Emanuel, Spiro, and Huelskoetter 2016).

CER and the Role of Government

What Is CER? The scope of CER includes conducting, supporting, and synthesizing research that compares the clinical outcomes, effectiveness, and appropriateness of ser- vices and procedures used to prevent, diagnose, and treat diseases and other health conditions. CER involves three major areas: (1) comparing new treat- ments for an illness with the best available alternatives for treating that illness, (2) using the information from CER to improve joint physician and patient decision making, and (3) basing the data on which these comparative studies are to be conducted on a sufficiently large population.

Physicians lack information on the effectiveness of alternative treatments for many diseases. For some illnesses, the relative effectiveness of alternative treatments has not been studied; for others, the results of effectiveness studies have not been disseminated to all physicians. The CER’s federal coordinating council has developed a priority list of diseases and is awarding grants to study the comparative effectiveness of alternative treatments for diseases highest on the priority list. CER is a continuing process that is conducted on more conditions as new treatments become available for illnesses whose alternative treatments previously were studied (Conway and Clancy 2009).

Why Is the Government Supporting CER? Public insurance programs, such as Medicare, and private health insurance pay for medical treatments regardless of how small the benefit or how large the cost. Under fee-for-service payment, neither insured patients nor their physi- cians have any incentive not to seek the most advanced medical treatments in search of a cure. Further, many policy experts acknowledge that insufficient

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C o p y r i g h t 2 0 1 9 . H e a l t h A d m i n i s t r a t i o n P r e s s .

A l l r i g h t s r e s e r v e d . M a y n o t b e r e p r o d u c e d i n a n y f o r m w i t h o u t p e r m i s s i o n f r o m t h e p u b l i s h e r , e x c e p t f a i r u s e s p e r m i t t e d u n d e r U . S . o r a p p l i c a b l e c o p y r i g h t l a w .

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Health Pol icy Issues: An Economic Perspect ive356

information exists on which treatments work best for different diseases. New drugs are typically compared with a placebo rather than with a drug already on the market.

Given the soaring cost of healthcare and the belief that each year hun- dreds of billions of dollars are spent on care that is of no value, more accurate information on which treatments perform better will improve quality of care and reduce the wide variations in treatment methods, thereby reducing ris- ing medical expenditures. Few people are opposed to providing consumers, physicians, and insurers with additional information on treatments that are more effective.

As shown in exhibit 22.1, several well-known academic medical centers were compared according to their total reimbursements per decedent, hospital days per decedent, and reimbursement per day for treating a patient during the last two years of his or her life. Wide variations existed among these medical centers in each of these measures. The study authors also showed that wide variations existed in the underlying resources, such as nurse staffing and physi- cian hours, used to treat these patients in the institutions. The federal govern- ment can play a crucial role in aggregating information about the effectiveness of various medicines and treatments and disseminating that information to physicians and their patients.

Academic Medical Center

Inpatient Reimbursements

per Decedent Hospital Days per Decedent

Reimbursements per Day

Johns Hopkins Hospital $93,233 26.5 $3,520

Ronald Reagan UCLA Medical Center

$79,182 29.1 $2,721

University of Maryland Medical Center

$78,753 25.3 $3,109

Hahnemann University Hospital

$63,932 26.7 $2,397

Massachusetts General Hospital

$53,159 25.6 $2,080

Cleveland Clinic Foundation

$41,769 21.9 $1,904

Mayo Clinic-St. Mary’s Hospital

$40,978 16.9 $2,429

Scott & White Memorial Hospital

$32,707 15.4 $2,118

Source: Data from Dartmouth Institute for Health Policy and Clinical Practice (2017).

EXHIBIT 22.1 Medicare Spending

per Decedent During the Last

Two Years of Life (Deaths Occurring in

2014), Selected Academic

Medical Centers

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Chapter 22: Comparat ive Ef fect iveness Research 357

Advocates of public funding for CER claim that such information has the characteristics of a public good—that is, everyone benefits from the infor- mation generated and that information cannot be denied to anyone once it becomes available. Because the information cannot be restricted to those who pay for it, the private sector (health plans) will invest too little to collect such information. Many, therefore, want government to fund CER and assist in the dissemination of such information.

Concerns over How CER Will Be Used

Using CER for Reimbursement Funding for CER generated a great deal of controversy when it was enacted in 2010. Critics were concerned that once the effectiveness of two treatments or drugs was determined, the relative costs of the two treatments would also be used to determine which drugs should be used. Fearful of being accused of promoting “death panels,” Congress prohibited the use of information based on CER for mandating coverage, reimbursement, or treatment decisions for public and private payers. However, many remain concerned that under the fiscal pressures of rising medical costs, use of CER results will eventually move closer to the way in which European countries use their findings on compara- tive effectiveness (Nix 2012).

Some opponents of government-funded CER believe that the govern- ment would ultimately use the findings from such research to establish medical practice guidelines, limit access to treatments, and refuse to pay for expensive new drugs. This concern was reinforced by a book by Tom Daschle, who was nominated by President Obama to become secretary of the US Department of Health and Human Services. (He subsequently withdrew his name amid a growing controversy over his failure to accurately report and pay income taxes.) Daschle had proposed a federal health board that would promote high-value medical care by recommending coverage of drugs and procedures based on the board’s research (Daschle, Greenberger, and Lambrew 2008).

Differences in Patient Responses to the Same Treatment CER is a one-size-fits-all approach to medicine; however, patients’ responses to different drugs vary widely. Those who do not respond well to the recom- mended treatment are at a disadvantage. For example, for most patients, a generic drug is cheaper and works as well as a brand-name drug. However, for some patients the generic version may cause serious side effects or have little effect. Thus, although a branded and a generic drug may be equally effective on average, not paying for the newer, more expensive drug may lead to increased hospitalization costs and worse health outcomes for those patients who do not respond well to the cheaper drug.

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Health Pol icy Issues: An Economic Perspect ive358

The problem with a one-size-fits-all approach is illustrated by a CER analysis of antipsychotic drugs, which found little difference between the effec- tiveness of older, less costly antipsychotic drugs and newer, more costly drugs. Using the older drugs could have saved Medicaid $1.2 billion (out of the $5.5 billion spent on these drugs in 2005). However, Basu, Jena, and Philipson (2011) concluded that the mental health of thousands of patients would have been worse and societal costs would have been greater than any savings from using the less costly drugs.

Variations in Medical Practice While most agree that wide variation occurs in medical practice, huge amounts of money are wasted on ineffective treatments and testing, and more information would be beneficial, there is opposition to moving from information genera- tion and dissemination to basing payment on CER. Zuckerman and colleagues (2010) attempted to explain why wide variations in medical spending occur. Using data on Medicare beneficiaries, they found that unadjusted Medicare spending per beneficiary was 52 percent greater in the highest-spending geo- graphic region than in the lowest-spending region. The authors then adjusted the regions based on demographics, baseline health characteristics, and changes in health status. The difference between the highest and lowest regions then decreased to 33 percent. Health status was found to explain an important part of this variation. Although inefficiency in spending per Medicare beneficiary exists, wide cost differences across geographic areas are not the result of inef- ficiency alone.

Policies to decrease spending differences per beneficiary between high- and low-cost areas by reimbursing physicians only for treatments that follow certain protocols or guidelines should not ignore the legitimate reasons for some of these variations.

Accuracy and Timeliness of Comparative Effectiveness Studies One study generally does not provide a definitive answer; several studies likely will have to be undertaken. For example, bone marrow transplantation for breast cancer was widely accepted as beneficial, and patients won lawsuits because some health plans refused to cover it. Subsequently, researchers found that this treatment was ineffective.

Comparative effectiveness studies may not adequately evaluate alterna- tive treatments for patients with multiple chronic diseases or rare illnesses. Similarly, CER often does not include sufficient numbers of women, African Americans, and Hispanics. Some drugs appear to be more effective in women than in men, while other medicines are more likely to cause serious complica- tions in women. CER must include larger numbers of patients in clinical trials so that gender and minority differences can be considered. As CER studies

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Chapter 22: Comparat ive Ef fect iveness Research 359

are expanded to account for such differences, the time and money needed to complete these clinical trials will increase (Chandra, Jena, and Skinner 2011).

Because it takes time to complete CER and for guidelines to be approved by the government, physicians and their patients may be willing to try untested therapies, as occurred for AIDS patients. Will they be permitted to do so? Will providers be reimbursed for these therapies?

CER and Innovation An additional concern is that CER might lead to slower adoption of new, more effective treatments. As new treatments and prescription drugs are developed, will reimbursement for them be delayed until their comparative effectiveness has been determined? Physicians might be willing to try new surgical tech- niques that offer the possibility of improved patient outcomes; will they and the hospital have to forgo payment because these techniques have not under- gone CER? Will the healthcare system become more rigid and less innovative because physicians fear repercussions if their treatments differ from the official guidelines? Will health plans refuse to reimburse for procedures and treatments that are not within the federal recommendations?

Medical device and pharmaceutical companies are also likely to face another layer of government approval that will increase their cost to bring a product to market, thereby decreasing their incentive for innovation.

Dissemination of CER Findings CER results must be disseminated. Will dissemination of information, which often is slow and may go against the financial interest of some physicians, be sufficient to lead to adoption of the CER? Or will financial incentives and reporting requirements be necessary? A concern with providing information to physicians is that their rate of adoption of new practices is very slow. If informa- tion is to change medical practice, lower costs, and improve quality, physician practice behavior will have to change more rapidly. However, without appropri- ate incentives, new information often takes years to change physician behavior.

Exhibit 22.2 provides several examples of the time from dissemination of information to treatment adoption by physicians. In 1988, the Food and Drug Administration approved the use of aspirin for treatment of heart attacks, which resulted in an increase in use from 20 percent to 62 percent. However, by the mid-1990s, aspirin use had only increased to 75 percent. After studies were published indicating the potential harmful effects of calcium-channel blockers, their use declined but remained above 30 percent ten years later.

Possible Stages in Use of CER Again, the legislation providing government funding for CER states that CER will not be used for reimbursement or coverage decisions. However, some people

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Health Pol icy Issues: An Economic Perspect ive360

believe that government funding of CER is just the first stage in its evolution. CER opponents foresee the following stages. First, CER provides information about the clinical effectiveness of different treatments and drugs for a disease. Second, their cost-effectiveness is compared. Third, given the rising costs of medi- cal care and the increasing burden on the federal deficit, the government only pays for those drugs and other treatments that are cost-effective, even though the effects may differ among people or population groups. Fourth, instead of deciding which drug it will pay for on the basis of cost-effectiveness, the govern- ment decides which drugs and treatments it will pay for by comparing the cost of the drug with the value of an additional year of life (as occurs in Great Britain).

The following sections examine cost-effectiveness, how CER might be used for reimbursement, and how CER is used in Great Britain.

Cost-Effectiveness Analysis

Cost-effectiveness analysis compares the additional costs of alternative approaches to achieve a specific outcome designed to improve health. For example, an organization interested in decreasing hip fractures would want to know the different programs that can reduce hip fractures, the cost of

Pharmaceuticals Year of

Innovation

Pharmaceutical Usea

1973– 1977

1978– 1982

1983– 1987

1988– 1992

1993– 1996

Beta blockers 1962 20.6 41.5 47.5 47.3 49.8

Calcium chan- nel blockersb

1971 0 0 63.9 59.0 31.0

Angiotensin- converting enzyme (ACE) inhibitors

1979 0 — — — 56.0

Aspirin 1988c 15.0 14.1 20.1 62.0 75.0

aIn hospital or 30-day use. bCalcium channel blocker use increased rapidly in the early 1980s and then fell, following the publi- cation of studies documenting potentially harmful effects of their use in acute management. cIn 1988, the Food and Drug Administration (FDA) proposed the use of aspirin for reducing the risk of recurrent myocardial infarction (MI), or heart attack, and preventing first MI in patients with unstable angina. The FDA also approved the use of aspirin for the prevention of recurrent transient ischemic attacks, or “mini-strokes,” in men and made aspirin standard therapy for previous strokes in men.

Source: Adapted from Cutler, McClellan, and Newhouse (1999, tables 3 and 5).

EXHIBIT 22.2 Use of Acute

Interventions (Pharma-

ceuticals) for Myocardial

Infarction

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Chapter 22: Comparat ive Ef fect iveness Research 361

expanding each program, and the extent of reduction in hip fractures each would achieve. Results from a cost-effectiveness analysis are typically presented in the form of a cost-effectiveness ratio, where the numerator of the ratio is the additional cost of the intervention and the denominator is some measure of the outcome of interest.

Alternative approaches for decreasing hip fractures are likely to differ in costs and effectiveness. Thus, they can be compared according to their cost- effectiveness ratio, which is the additional cost per averted hip fracture. (For an example of cost-effectiveness analysis, see exhibit 3.3.)

Calculating the cost-effectiveness ratio for each alternative method of achieving a given health outcome allows a comparison of the trade-offs from choosing one alternative over another. Decision makers—whether they are administrators in government agencies such as Medicaid or health maintenance organization managers—can make better-informed choices about the relative costs and effectiveness of alternative interventions by using cost-effectiveness analysis. When selecting among alternative expenditures to improve health, alternative interventions can be ranked according to their cost-effectiveness ratios (e.g., cost per death averted), giving the intervention with the lowest ratio the highest priority. Choosing interventions on the basis of the lowest cost-effectiveness ratio maximizes the outcome for a given budget.

Many cost-effectiveness studies have been conducted on the relative effectiveness of a new drug compared with existing drugs for treating the same disease. The originators of such studies include health plans seeking to determine which drugs to include in their formularies and pharmaceutical firms hoping to use the results to demonstrate to large purchasers the greater effectiveness of their new drugs compared with those of competitors.

A concern with cost-effectiveness analysis if used for reimbursement by the government is that, as discussed earlier, patients may differ in their response to a drug or other treatment. Medical costs could be higher if patients respond poorly to certain drugs and must be hospitalized. Further, the government’s cost-effectiveness ratio may be different from the patient’s cost or evaluation of the treatment’s effectiveness.

Quality-Adjusted Life Years

A specific type of cost-effectiveness analysis uses quality-adjusted life years (QALYs) as an outcome measure. QALYs indicate the increased utility achieved as the result of an intervention, such as comparing a new drug to an existing one. The cost-effectiveness ratios are in terms of the cost per QALYs gained. The advantage of using QALYs rather than, for example, life expectancy is that QALY incorporates multiple outcomes—increase in length of life and quality

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Health Pol icy Issues: An Economic Perspect ive362

of life. Using QALYs as an outcome measure also enables comparisons to be made across different disease conditions.

QALY is calculated as follows: Each additional year of perfect health for an individual is assigned a value of 1.0, which is the highest value of a complete QALY. The assigned value decreases as health decreases, with death equal to 0.0. If the patient has various limitations—such as a disability, physical pain, or receipt of kidney dialysis—the extra life years are assigned a value between 1.0 and 0.0. Thus, if new intervention A enables a person to live an additional five years, but with a quality of life weight of 0.7, then the QALY score for that intervention is 5 × 0.7 = 3.5 QALYs. If intervention B extends life for four years with a quality of life weight of 0.6, the additional QALYs provided are 4 × 0.6 = 2.4. The net benefit of intervention A over intervention B is 3.5 QALYs – 2.4 QALYs = 1.1 QALYs.

When comparing alternative interventions according to their additional cost per QALY, those with a lower cost per QALY are preferred to those with a higher cost per QALY. A common approach for developing QALYs involves the use of an activities of daily living (ADL) scale. Patients are asked to rate their ability to function independently, such as dressing, bathing, and walk- ing. Patient responses range from unable to perform the function to able to perform the function without difficulty. These scores are summed over all the ADL categories to arrive at a patient’s overall functional status.

The calculation of QALYs is the same regardless of a person’s income, wealth, or age; however, QALYs that occur in later years may be valued less than QALYs occurring earlier in life.1

QALYs have several drawbacks. For example, QALY does not include the effects of a patient’s disability on the quality of life of others, such as fam- ily members. Assigning a quantitative value to a disability may not be accurate because people differ in their perceptions of the severity of various limitations on their normal activity. Further, applying these utility measures across a large, diverse population is unlikely to reflect many individuals’ utility preferences. Yet using QALYs for a large population is necessary if alternative medical treat- ments are to be compared.

Applications of QALYs QALYs have been used in two types of policy analysis. First, they are used as an outcome measure in cost-effectiveness analysis to compare alternative inter- ventions in determining which intervention offers the lowest cost per QALY. Second, and more controversial, cost per QALY has been used to determine benefit coverage—for example, to decide whether a costly treatment, such as an expensive new drug, should be provided to a breast cancer patient (Baum- gardner and Neumann 2017).

Exhibit 22.3 shows the results of several cost-effectiveness studies exam- ining different drug therapies potentially applicable to the Medicare popula- tion. Each study describes an intervention compared with the alternative of no

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Chapter 22: Comparat ive Ef fect iveness Research 363

treatment. The results, in the form of cost per QALY gained, are ranked from lowest to highest cost per QALY. Therapies whose cost per QALY is relatively low (e.g., $4,000) are very favorable. Therapies with a relatively high cost per QALY (e.g., $460,000) are considered unfavorable and less likely to be adopted.

The National Institute for Health and Care Excellence

Great Britain established the National Health Service (NHS) in 1948 as a single- payer system, administered by the government, funded through taxation, and provided by public institutions. The British government has a long history of underfunding the NHS, resulting in long waiting lines and failure to provide certain types of treatments. To limit expenditures on expensive innovative medical technology and drugs and to attempt to rationalize its limited budget, in 1999 the government formed the National Institute for Clinical Excellence (NICE)— now called the National Institute for Health and Care Excellence—a private,

Intervention vs. Base Case in Target Population Dollars per

QALY Gained

Captopril therapy vs. no captopril in 80-year-old patients surviv- ing myocardial infarction

$4,000

Treatment with mesalazine vs. no treatment to maintain remis- sion in Crohn’s disease

$6,000

One-year course of isoniazid (INH) chemoprophylaxis vs. no INH chemoprophylaxis in 55-year-old white male tuberculin reactors with no other risk factors

$18,000

Treatment to reduce the incidence of osteoporotic hip frac- ture vs. no treatment in 62-year-old woman with established osteoporosis

$34,000

Ticlopidine vs. aspirin in 65-year-old with high risk of stroke $48,000

Chemotherapy vs. no chemotherapy in 75-year-old with breast cancer

$58,000

Captopril vs. propranolol in persons in the US population aged 35–64 years without the diagnosis of coronary heart disease but with essential hypertension

$150,000

Antiemetic therapy with ondansetron vs. antiemetic therapy with metoclopramide in 70-kg patient receiving cisplatin chemo- therapy who had not been previously exposed to antineoplastic agents

$460,000

Note: QALY = quality-adjusted life year.

Source: Adapted from Neumann and colleagues (2000, exhibit 3).

EXHIBIT 22.3 Selected Cost- Effectiveness Ratios for Pharma ceu- ticals, with a Focus on the Medicare Population

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Health Pol icy Issues: An Economic Perspect ive364

independent organization in the Department of Health, to provide guidance on health technology, clinical medicine, and new prescription drugs. Its decisions are based on clinical efficacy and cost-effectiveness (NICE 2018; Rawlins 2013).

NICE uses QALYs to determine which treatments to cover in the NHS. Given that budget constraints exist on the amount the government can spend for medical services, NICE undertakes cost-effectiveness analysis for new drugs and treatments in an attempt to provide patients, health professionals, and the public with scientifi- cally based guidance on current best practices. A NICE committee consisting of medical and other professionals, such as health economists, statisticians, managers, patient advocates, and manufacturer representatives, assists in its decision making.

Before NICE was established, the availability of costly treatments varied greatly throughout the country, as did the level of medical services. NICE has made the availability of drugs and treatments more uniform throughout the NHS. Decisions by NICE are transparent to all, and the information on which it bases its decisions is also publicly available. Further, when NICE believes that a treatment or drug is cost-beneficial, it attempts to ensure that the treatment or drug becomes widely available.

The main criticism of NICE is that it bases its recommendations primarily on cost-effectiveness rather than on clinical effectiveness (Hope 2011; Steinbrook 2008). The criticism that NICE is coldhearted stems from the fact that it uses cost per QALY to determine cost-effectiveness. One of NICE’s most contentious issues is how much should be spent per additional year of life that a drug is expected to provide. NICE’s general threshold is about $66,000 per QALY. If a treatment’s cost per QALY is higher, NICE will generally deny the treatment. (In 2016, NICE set the cost per QALY threshold for treatment of rare diseases at $132,000.)

The following example illustrates how NICE uses its cost per QALY to determine approval for costly treatments. A New York Times article tells the story of Bruce Hardy, a patient fighting kidney cancer that was spreading throughout his body (Harris 2008). His physician wanted to prescribe a new drug from Pfizer called sunitinib malate (Sutent), which delays cancer progres- sion for six months at a cost of $54,000. NICE, however, decided that the drug was too costly to be offered free to all those who needed it. According to NICE, the cost of extending life for six months should be no more than $22,750; therefore, Hardy could not receive the drug. When NICE rejected Sutent, some patients mortgaged their homes to pay for the drug on their own. After much protest, NICE reversed its decision and approved the drug. NICE has also limited the use of certain breast cancer drugs, such as trastuzumab (Herceptin), and drugs for osteoporosis and multiple sclerosis.

Great Britain has been explicit in recognizing that resources are scarce and choices must be made on how to allocate those scarce resources. At some point, with rising medical costs and a huge government deficit, will the United States become as explicit or, more likely, make such decisions implicitly by

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Chapter 22: Comparat ive Ef fect iveness Research 365

limiting healthcare provider reimbursement, thereby limiting the resources available for new technology and expensive drugs?

Summary

CER should provide additional information to physicians and their patients regarding the effectiveness of alternative treatments. To the extent that wide varia- tions in medical practice are the result of lack of information, CER should improve patient outcomes and reduce medical costs. However, if the CER findings are used for reimbursement or coverage decisions, some patients may suffer adverse health consequences, and the medical system could become less innovative.

Some policy experts are concerned that federal funding for CER is but the first step toward limiting government payment for treatments considered less effective than others or too expensive with respect to their return in extend- ing life expectancy. If CER studies demonstrate that a new drug for $1,000 a year usually provides greater benefits than a $50,000 surgical procedure, but the financial incentive for many surgeons is to continue performing the more expensive procedure, will insurers and the government continue to pay for both treatments? Great Britain’s NICE is often cited as an example of a government agency that determines which medical treatments will be covered based on cost-effectiveness. Using cost-effectiveness, NICE covers only those treatments that do not exceed a certain threshold, such as the cost per QALY not exceeding the value of a life. Although the ACA states that CER shall not be used as a basis for payment, some are concerned that the United States may eventually use cost-effectiveness in reimbursement of medical services.

Society cannot spend an infinite amount of money to extend each person’s life; choices must be made. Economics requires trade-offs because resources are scarce and can be spent on enhancing life in other ways. The opportunity cost of spending $100,000 on a new drug that extends the life of a terminally ill patient by three months is that those same funds could be spent on prenatal care or to increase the life expectancy of very-low-birthweight infants. Spending resources on additional medical services to extend one per- son’s life involves having fewer resources to spend on extending the lives of others. States and the federal government, faced with higher limits on their expenditures and increasing demands for costly medical services, will have to make difficult choices in coming years.

The proposal to create a separate federal health board to make difficult political decisions regarding which medical services and prescription drugs to fund insulates legislators from making these difficult choices, such as denying expensive but potentially life-extending services to a patient whose need for the treatment has been discussed in the media.

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Health Pol icy Issues: An Economic Perspect ive366

Discussion Questions

1. What are the advantages of CER? 2. What are disadvantages of using CER for federal payment? 3. What are QALYs? 4. How are QALYs used in cost-effectiveness analysis? 5. How does NICE use QALYs in determining whether to approve a new

drug?

Note

1. When interventions produce QALYs over different periods, discounting may be used to convert them into equivalently valued units at the present period, similar to discounting future income streams (as is done in a cost–benefit analysis). To determine the present value of future QALYs, the number of QALYs in each future year should be multiplied by (1/1 + rt), where r is the discount rate—such as 0.05—and t represents the number of years from the future to the present.

Additional Readings

Health Affairs. 2012. “Current Challenges in Comparative Effectiveness Research.” Published October. www.healthaffairs.org/toc/hlthaff/31/10.

———. 2010. “Comparative Effectiveness Research.” Published October. www.health affairs.org/toc/hlthaff/29/10.

Neumann, P. J., J. T. Cohen, and M. C. Weinstein. 2014. “Updating Cost-Effectiveness: The Curious Resilience of the $50,000-per-QALY Threshold.” New England Journal of Medicine 371 (9): 796–97.

References

Basu, A., A. Jena, and T. Philipson. 2011. “Impact of Comparative Effectiveness Research on Health and Healthcare Spending.” Journal of Health Economics 30 (4): 695–706.

Baumgardner, J., and P. J. Neumann. 2017. “Balancing the Use of Cost-Effectiveness Analysis Across All Types of Health Care Innovations.” Health Affairs Blog. Posted April 14. www.healthaffairs.org/do/10.1377/hblog20170414.059610/ full/.

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Chapter 22: Comparat ive Ef fect iveness Research 367

Chandra, A., A. Jena, and J. Skinner. 2011. “The Pragmatist’s Guide to Comparative Effectiveness Research.” Journal of Economic Perspectives 25 (2): 27–46.

Conway, P., and C. Clancy. 2009. “Comparative-Effectiveness Research: Implica- tions of the Federal Coordinating Council’s Report.” New England Journal of Medicine 361 (4): 328–30.

Cutler, D., M. McClellan, and J. Newhouse. 1999. “The Costs and Benefits of Intensive Treatment for Cardiovascular Disease.” In Measuring the Prices of Medical Treat- ments, edited by J. Triplett, 34–71. Washington, DC: The Brookings Institution.

Dartmouth Institute for Health Policy and Clinical Practice. 2017. “Care of Chronically Ill Patients During the Last Two Years of Life.” Dartmouth Atlas of Health Care. Accessed April 2018. www.dartmouthatlas.org/tools/downloads.aspx?tab=40.

Daschle, T., S. Greenberger, and J. Lambrew. 2008. Critical: What We Can Do About the Health-Care Crisis. New York: Thomas Dunne Books.

Emanuel, Z., T. Spiro, and T. Huelskoetter. 2016. “Re-evaluating the Patient-Centered Outcomes Research Institute.” Center for American Progress. Posted May 31. www.americanprogress.org/issues/healthcare/reports/2016/05/31/138242/ re-evaluating-the-patient-centered-outcomes-research-institute/.

Harris, G. 2008. “British Balance Benefit vs. Cost of Latest Drugs.” New York Times. Published December 2. www.nytimes.com/2008/12/03/health/03nice.html.

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EBSCOhost - printed on 2/6/2023 8:36 AM via UNIVERSITY OF MARYLAND GLOBAL CAMPUS. All use subject to https://www.ebsco.com/terms-of-use