Can I interrupt your repeating a Medicare press release to talk about cost-effectiveness?

I feel so many of my recent pieces are coming together in this one.

Medicare has made a decision to pay for lung cancer screening in older smokers with CT scans. Since I pointed out yesterday that lung cancer is now the number one cancer killer in the developed world, this is timely. Further, the USPSTF has recommended such screening with a grade of B since the end of 2013. As I’ve written before at The Upshot, the ACA mandates coverage of all USPSTF recommendations with an A or B to be available to people without co-pays, free of charge.

And let’s be clear. This is one of those screening tests that seems to work. It’s got an NNT to prevent death of 217, which isn’t that bad. (Of course, there are lots of harms, too, but let’s let that go for a minute.)

Given that it works, it’s recommended by the USPSTF, and lung cancer is a big problem – this decision isn’t a surprise. But… how much will this cost? First, let’s look at the news coverage. NBC News:

Experts project that the screening test, which costs $250-$300, may prevent as many as 20 percent of deaths from lung cancer, making it akin to mammograms and colonoscopies in terms of saving lives.

A study published last May projected that paying for lung cancer screening would cost Medicare $9 billion over five years, or about $3 per month per beneficiary.

That sounds awesome! How can we not cover that? But here’s another way of looking at the same thing, from a paper in JAMA:

Over a 20-year period, assuming a 50% stage shift, the current heavy smoker cohort had 553 fewer lung cancer deaths (13% lung cancer-specific mortality reduction) and 1186 false-positive invasive procedures per 100 000 persons. The incremental cost-effectiveness for current smokers was $116 300 per QALY gained. For quitting and former smokers, the incremental cost-effectiveness was $558 600 and $2 322 700 per QALY gained, respectively.

Wait, what? For current smokers, the cost effectiveness for current smokers of this screening was $116,000 per QALY. For former smokers – which Medicare is going to cover – the incremental cost-effectiveness was more than $2.3 million per QALY. And this study was using 2001 $US, cause it was published back in 2003.

Now, people in this country may think that’s money well spent. That’s fine. But let’s acknowledge that this is a pretty high cost per QALY gained. I see nothing but praise for this development in the media, while Sovaldi (incremental cost-effectiveness of less than $26,000 per QALY $54,000 per QALY) is often portrayed as a budget-busting, crazily priced monstrosity.

Please understand that I’m not arguing for or against any of these tests or treatments. I just think that we should talk about it. Might be nice to have a conversation about efficiency in our spending once in a while. I’m just saying.


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