Current Opinion

PharmacoEconomics

, Volume 32, Issue 8, pp 729-733

First online:

Do Changes in Drug Coverage Policy Point to an Increased Role for Cost-Effectiveness Analysis in the USA?

  • James D. ChambersAffiliated withThe Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center Email author 

Abstract

Compared with other countries, cost-effectiveness analysis has traditionally had a limited role in US health care. Rather, US payers have typically accommodated the introduction of expensive technology by passing an increasing proportion of costs to patients, through raising insurance premiums and/or by increasing copayments, coinsurance, and deductibles. However, in what may prove to be a tipping point, the two largest pharmacy benefit managers have chosen to exclude drugs from their formularies that offer uncertain health benefit compared with cheaper alternatives. This paper argues that cost-effectiveness analysis should be used to inform these value-based decisions, and that by using information other than robust cost-effectiveness evidence, payers risk wrongly denying beneficiaries access to important medical technologies. If cost-effectiveness analysis were to be used in this way, it would be another in a growing number of examples of its use across public and private payers. In the absence of a centralized agency conducting cost-effectiveness analysis, the recently inaugurated 2nd Panel on Cost-Effectiveness in Health and Medicine has an important role to play in standardizing methods and promoting best practice.