A Comparison of Technology Coverage Decisions in the U.S. and the U.K. -- Seeing the NICE Side of Cost-effectiveness Analysis

The research to be discussed in this seminar concerns technology coverage policy in both public and private healthcare settings. The term "coverage" as used here refers to the setting of limits on the healthcare services that are available for reimbursement. Presenter Stirling Bryan will describe research he has recently completed in the United Kingdom, as well as research he will soon begin in the United States, as part of his Harkness Fellowship to be conducted at CHP/PCOR.

Bryan's UK-based research explored the use and influence of economic analyses in national technology coverage decisions, and considered how the impact of such analyses might be increased. At a national level in the UK, coverage decisions are made by the National Institute for Health and Clinical Excellence (NICE). The Institute can be viewed as an experiment in the explicit use of cost-effectiveness analysis to inform national health policy -- an independent economic analysis is commissioned for every appraisal topic.

Bryan's research was qualitative; fieldwork was conducted over 12 months and focused on 7 technologies. The researchers analyzed literature made available to one of the committees within NICE that evaluate specific medical technologies to determine their level of coverage. The researchers also observed formal meetings of the committee and interviewed 30 of its members. The themes identified from this research are grouped under three headings: political (i.e. committee composition and roles of members), concepts and processes (including committee operation and conceptual challenges), and practical issues. The research primarily highlights the value of cost-effectiveness analysis not only in providing overall direction for coverage decisions, but also in giving structure and focus to such discussions. Concerns exist in relation to cost-effectiveness analysis concepts (e.g. the quality-adjusted life year, or QALY) and practical issues of how such analysis is to be used.

Bryan's research in the United States will seek to describe processes and principles underlying U.S. coverage policy in both public (e.g. Medicare) and private (e.g. Kaiser) systems, and to assess the use made of cost-effectiveness information. In addition, it will explore the impact of wider use of a cost-effectiveness criterion. Bryan and his collaborators will elicit stakeholder views on coverage policy in general (including the views of members of the general public), as well as views on the use of efficiency criteria in particular. The work will lead to recommendations on how coverage policy in both the UK and the United States might be strengthened.