What does the value of modern medicine say about the $50,000 per quality-adjusted life-year decision rule?
BACKGROUND
In the United States, $50,000 per Quality-Adjusted Life-Year (QALY) is a decision rule that is often used to guide interpretation of cost-effectiveness analyses. However, many investigators have questioned the scientific basis of this rule, and it has not been updated.


METHODS
We used 2 separate approaches to investigate whether the $50,000 per QALY rule is consistent with current resource allocation decisions. To infer a lower bound for the decision rule, we estimated the incremental cost-effectiveness of recent (2003) versus pre-"modern era" (1950) medical care in the United States. To infer an upper bound for the decision rule, we estimated the incremental cost-effectiveness of unsubsidized health insurance versus self-pay for nonelderly adults (ages 21-64) without health insurance. We discounted both costs and benefits, following recommendations of the Panel on Cost-Effectiveness in Health and Medicine.


RESULTS
Our base case analyses suggest that plausible lower and upper bounds for a cost-effectiveness decision rule are $183,000 per life-year and $264,000 per life-year, respectively. Our sensitivity analyses widen the plausible range (between $95,000 per life-year saved and $264,000 per life-year saved when we considered only health care's impact on quantity of life, and between $109,000 per QALY saved and $297,000 per QALY saved when we considered health care's impact on quality as well as quantity of life) but it remained substantially higher than $50,000 per QALY.


CONCLUSIONS
It is very unlikely that $50,000 per QALY is consistent with societal preferences in the United States.
Braithwaite
R Scott
RS
Department of Medicine, Section of General Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA. Ronald.braithwaite@va.gov
Meltzer
David O
DO
King
Joseph T
JT
Leslie
Douglas
D
Roberts
Mark S
MS
D000328:Adult; D017677:Age Distribution; D003362:Cost-Benefit Analysis; D003661:Decision Support Techniques; D005260:Female; D015276:Health Care Rationing / Q000191:economics*; D006291:Health Policy; D006801:Humans; D007348:Insurance, Health / Q000191:economics; D008017:Life Expectancy; D008297:Male; D008875:Middle Aged; D019057:Quality-Adjusted Life Years; D012016:Reference Values; D013997:Time Factors; D014481:United States