A Health Opportunity Cost Threshold for Cost-Effectiveness Analysis in the United States

Background Cost-effectiveness analysis is an important tool for informing treatment coverage and pricing decisions, yet no consensus exists about what threshold the incremental cost-effectiveness ratio (ICER) in dollars per quality-adjusted life-year (QALY) gained indicates whether treatments are likely to be cost-effective United States. Objective To estimate a U.S. based on health opportunity costs. Design Simulation of short-term mortality morbidity attributable persons dropping insurance due increased care expenditures passed though as premium increases. Model inputs came from demographic data literature; 95% uncertainty intervals (UIs) were constructed. Setting Population-based. Participants Simulated cohort 100 000 individuals population with direct-purchase private insurance. Measurements Number coverage, number additional deaths, QALYs lost morbidity, all increase $10 (2019 dollars) cost. Results Per expenditures, 1860 (95% UI, 1080 2840 persons) simulated become uninsured, causing 5 deaths (UI, 3 11 deaths), 81 40 170 QALYs) death, 15 6 32 illness; this implies $104 QALY $51 $209 QALY) 2019 dollars. Given available evidence, there 14% probability that exceeds $150 48% it lies below $100 QALY. Limitations Estimates sensitive inputs, most notably effects losing increases becoming uninsured. Health costs may vary by population. Nonhealth excluded. Conclusion current ICERs above range unlikely Primary funding source None.