High-priced technology can be good value for money.

M edical technology is now subject to the same economic scrutiny that was historically reserved for public health and disease prevention programs. It has long been true that vaccination, health education, and screening programs have been required by both public and private health care agencies to prove their economic worth before they could be funded. A frequently encountered criterion for funding of prevention programs is that they must save more money than they spend—the test of " cost savings " (1) or, in a term heard in government circles these days, budget neutrality. As pointed out by Russell (2) and others (3, 4), it is unrealistic to expect disease prevention programs, in general, to be budget neutral. Most preventive efforts cost more money than they save, even those as beneficial as vaccination to prevent pneumococcal pneumonia in elderly persons (5); treatment for high blood pressure (6); and screening for breast, colon, and cervical cancer (7–9). The appropriate criterion for funding of preventive medicine and public health is not cost savings, but acceptable value for money. A program's cost-effectiveness ratio is a measure of just that: How much does it cost to purchase a gain in health outcome? Unfortunately, there is no clear standard for what constitutes good value for money. Cost-effectiveness ratios are often placed in context by comparisons with interventions that are widely mandated , such as annual screening mammography for women 55 to 65 years of age at $20 000 to $90 000 per life-year gained (7) or hemodialysis for end-stage renal disease at $60 000 to $128 000 per quality-adjusted life-year (QALY) (10). No consensus defines the cost per QALY that represents acceptable value for money (11). The implicit and explicit decisions of patients, physicians, insurers, employers, and government agencies and legislators make it clear that Americans are willing to spend money to get better health outcomes, even though the amount that they are willing to spend on health care is not unlimited. What a difference a decade makes! In the good old days, when prevention was subjected to the critical eye of economic evaluation, high-technology clinical medicine escaped this kind of scrutiny. Medical care, after all, was " free " because somebody else paid for it. Now, with price competition among health care plans and provider groups in the United States, the test of budget neutrality is starting to be used to restrict the flow of …