By James Chambers, PhD
In a new paper published in Health Policy, my colleagues and I investigated the use of cost-effectiveness analysis (CEA) in Medicare coverage of prevention. We found that cost-effectiveness has played a longstanding role in coverage determinations for several preventive health services. In contrast, no such consideration is used in coverage of treatments. While Medicare once dealt primarily with paying claims for treatments, preventative services have been gradually added to the program, with their addition becoming more commonplace over the past ten years. There has been little examination to date of the role CEA has played in coverage determinations for preventive measures.
When preventive services were initially added to the program, it was through Congressional action that required evidence of affordability. Of the 23 preventive services currently covered by Medicare, CEA played a role in coverage for nine. For example, CEA was used in coverage determinations for pneumococcal vaccine (1981), HIV screening (2010), and screening and behavioral counseling for alcohol misuse (2011). In addition, CEA was considered in multiple cases when Medicare decided not to cover a preventive service, e.g., screening computed tomography colonography (CTC) for colorectal cancer.
In other ways, the US has increasingly made efforts to promote preventive care – such as the addition of the annual wellness visit to the Medicare benefits package (2011). However, by evaluating the cost-effectiveness of preventive services and not treatment, the government holds prevention to a stricter evidence standard. Using CEA for prevention and not for treatment is a double standard. Expanding the role of CEA in Medicare coverage to include treatment would add balance and evidence to the process, and efficiency to the program.
1. Chambers, JD, Cangelosi, MJ, Neumann, PJ. Medicare’s use of cost-effectiveness analysis for prevention (but not for treatment). Health Policy 2014 Nov 22. [Epub ahead of print]