Cost-effectiveness analysis (CEA) may provide the best value for average American’s healthcare dollar. As a nation, we spend more per person on healthcare than any other country in the world, yet we still have those who are uninsured or underinsured. With the implementation of the Affordable Care Act (ACA) there was hope that all Americans would be covered by healthcare insurance, but the fear related to resource allocation and CEA remains strong. Many believe that it is unjust and is biased against those who are old or sick, but it is my belief that CEA is not only just, but upholds Rawls theory of distributive justice. The theory of distributive justice holds that the inequalities of economic or social are only to be allowed if the worst off will be better off than under equal distribution. To understand why this is true, the World Health Organization’s parameters for cost effective interventions will be used as a guideline.
The World Health Organization has a rule of thumb: Three times per person income per quality-adjusted life year (QALY) gained is a cost effective intervention (1). The WHO bases its cost-effective threshold on a country’s gross domestic product, (GDP). The WHO’s model states “an intervention that, per disability-adjusted life-year (DALY) avoided, costs less than three times the national annual GDP per capita is considered cost–effective, whereas one that costs less than once the national annual GDP per capita is considered highly cost–effective” (2). Using this as a guide, we can then average the income of most Americans to determine what a reasonable intervention cost is. The use of CEA places equal value on each person’s life regardless of their financial, educational or social level, thus supporting the goal of the ACA to provide equal access to affordable basic healthcare.
As a society, we cannot ignore the high cost of healthcare in America. The high cost can be linked to waste and high administration expenditures, which are inherent in how healthcare is currently delivered. To reduce the expenditures while increasing access, it is necessary to analyze how we are spending our healthcare dollar to ensure that those who need healthcare can access the care they need. The use of CEA will help to reduce healthcare expenditures while meeting the needs of the people as the goal of CEA is to provide the best healthcare at the best value. The issue then becomes educating the public about CEA and how it increases access to healthcare for those who may not have been able to receive care before it’s use. CEA is ethical precisely because of what it can do for society.
CEA allows for the use of the best value regardless of whether the treatment is new or old. It takes into consideration how the treatment works, the short and long term effects and the life years it may add onto to a person’s life. CEA does not look at financial status, social standing or a person’s perceived value to society; it simply used to look at the benefit of the treatment to the person. Furthermore, CEA takes into consideration alternative forms of treatment that may be more effective. It considers counseling, preventative health, and other interventions. The interventions may be more affordable and accessible to those in society than the aftercare necessary once an event has occurred. Interventions provide equal access to education and participation for all, regardless of socioeconomic status (SES). Unfortunately, interventions are often underutilized. Interventions in healthcare should become a standard of care since they increase wellness, and healthy people are better able to access financial, educational and societal resources.
Healthcare costs will continue to rise without a system that analyzes the cost of treatments. If society allows healthcare costs to continue to rise at an unchecked pace, the disparities between different SES’s ability to access to healthcare will continue to grow. Healthcare costs should be viewed from society’s perspective, taking into consideration not just the cost of the treatment or intervention, but the effect that healthcare expenditures will have on society as a whole. While there are other options to measure the cost of healthcare, such as cost benefit analysis, these options are timely, complicated and do not look at the system as a whole but instead as parts. The use of CEA and QALY’s may not be perfect, but they are preferred because they have potential to allow for better quality of life while decreasing mortality , which would include treatment benefits and side effects.
1. Edejer, T. Tan-Torres, Baltussen, R., Adam, T., Hutubessy, R., Acharya, A., Evans, D.B. & Murray, C.J.L. (eds.) (2003). WHO Guide to Cost - Effectiveness Analysis. World Health Organization. Geneva, Switzerland. Retrieved from: http://www.who.int/choice/publications/p_2003_generalised_cea.pdf.
2. Marseille,Elliot, Larson,Bruce, Kazi,Dhruv S, Kahn,James G, and Rosen,Sydney “Thresholds for the cost–effectiveness of interventions: alternative approaches” Bulletin of the World Health Organization 2015;93:118-124. doi: http://dx.doi.org/10.2471/BLT.14.138206.