The Value of Home Health Physical Therapy.

The purpose of the Triple Aim is to improve population health, reduce healthcare costs, and improve the patient experience. These goals-to reduce cost while improving health outcomes and patient experiences have shifted utilization of services from other postacute care settings to the home. The purpose of this perspective article is to discuss how home healthcare services, and home physical therapy (PT) specifically, provide value to patients, caregivers, and payers to meet the goals of the Triple Aim. This article will substantiate the value of home PT and provide healthcare professionals with evidence-based information on the value of home PT.

What Can We Expect from Value-Based Funding of Medicines? A Retrospective Study.

OBJECTIVE: Deciding on public funding for pharmaceuticals on the basis of value for money is now widespread. We suggest that evidence-based assessment of value has restricted the availability of medicines in Australia in a way that reflects the relative bargaining power of government and the pharmaceutical industry. We propose a simple informal game-theoretic model of bargaining between the funding agency and industry and test its predictions using a logistic multiple regression model of past funding decisions made by the Pharmaceutical Benefits Advisory Committee in Australia. METHOD: The model estimates the probability of a drug being recommended for subsidy as a function of incremental cost per quality-adjusted life-year (QALY), as well as other drug and market characteristics. Data are major submissions or resubmissions from 1993 to 2009 where there was a claim of superiority and evidence of a difference in quality of life. Independent variables measure the incremental cost per QALY, the cost to the public budget, the strength and quality of the clinical and economic evidence, need as measured by severity of illness and the availability of alternative treatments, whether or not a resubmission, and newspaper reports as a measure of public pressure. We report the odds ratio for each variable and calculate the ratio of the marginal effect of each variable to the marginal effect of the cost per QALY as a measure of the revealed willingness to pay for each of the variables that influence the decision. RESULTS: The results are consistent with a bargaining model where a 10,000 Australian dollar ($A) fall in value (increase in cost per QALY) reduces the average probability of public funding from 37 to 33% (95% CI 34-32). If the condition is life threatening or the drug has no active comparator, then the odds of a positive recommendation are 3.18 (95% CI 1.00-10.11) and 2.14 (95% CI 0.95-4.83) greater, equivalent to a $A33,000 and a $A21,000 increase in value (fall in cost per QALY). If both conditions are met, the odds are increased by 4.41 (95% CI 1.28-15.24) times, equivalent to an increase in value of $A46,000. Funding is more likely as time elapses and price falls, but we did not find clear evidence that public or corporate pressure influences decisions. CONCLUSION: Evidence from Australia suggests that the determinants of public funding and pricing decisions for medicines reflect the relative bargaining power of government and drug companies. Value for money depends on the quality of evidence, timing, patient need, perceived benefit and opportunity cost; these factors reflect the potential gains from striking a bargain and the risk of loss from not doing so.

Using effectiveness and cost-effectiveness to make drug coverage decisions: a comparison of Britain, Australia, and Canada.

CONTEXT: National public insurance for drugs is often based on evidence of comparative effectiveness and cost-effectiveness. This study describes how that evidence has been used across 3 jurisdictions (Australia, Canada, and Britain) that have been at the forefront of evidence-based coverage internationally. OBJECTIVES: To describe how clinical and cost-effectiveness evidence is used in coverage decisions both within and across jurisdictions and to identify common issues in the process of evidence-based coverage. DESIGN, SETTING, AND PARTICIPANTS: Descriptive analysis of retrospective data from the Common Drug Review (CDR) of Canada, National Institute for Health and Clinical Excellence (NICE) in Britain, and Pharmaceutical Benefits Advisory Committee (PBAC) of Australia. All publicly available information as of December 31, 2008, was gathered from each committee's Web site (data set begins in January 2004 [CDR], February 2001 [NICE], and July 2005 [PBAC]). MAIN OUTCOME MEASURE: Listing recommendations for each drug by disease indication. RESULTS: NICE recommended 87.4% (174/199) of submissions for listing compared with a listing rate of 49.6% (60/121) and 54.3% (153/282) for the CDR and PBAC, respectively. Significant uncertainty around clinical effectiveness, typically resulting from inadequate study design or the use of inappropriate comparators and unvalidated surrogate end points, was identified as a key issue in coverage decisions. Recommendations varied considerably across countries, possibly because of differences in the medications reviewed; different agency processes, including the willingness to negotiate on price; and the approach to "me too" drugs. The data suggest that the 3 agencies make recommendations that are consistent with evidence on effectiveness and cost-effectiveness but that other factors are often important. CONCLUSIONS: NICE, PBAC, and CDR face common issues with respect to the quality and strength of the experimental evidence in support of a clinically meaningful effect. However, comparative effectiveness and cost-effectiveness, along with other relevant factors, can be used by national agencies to support drug decision making. The results of the evaluation process in different countries are influenced by the context, agency processes, ability to engage in price negotiation, and perhaps differences in social values.

An economic evaluation of increased uptake in Q fever vaccination among meat and agricultural industry workers following implementation of the National Q Fever Management Program.

INTRODUCTION: Q fever is a serious but vaccine-preventable infectious disease that predominantly affects those working in the meat and agricultural industries. In October 2000, the Commonwealth Government introduced the National Q Fever Management Program. This economic evaluation assesses the cost-effectiveness and cost-utility of improved vaccine uptake among meat and agricultural industry workers. METHODS: Separate analyses were conducted for meat and agricultural industry workers. Clinical and epidemiological data used to create the models were obtained from published sources. Markov modelling was used to estimate the impact of Q fever vaccination uptake on the direct costs and outcomes of Q fever over a 20-year period. RESULTS: Increasing vaccine uptake from 65% to 100% among meat industry workers results in an incremental cost per life year gained of $20,002, and a cost per QALY of $6,294. Increasing vaccine uptake from zero to 20% among agricultural industry workers results in an incremental cost per life year gained of $24,950, and a cost per QALY of $7,984. Including some indirect costs in the form of Workcover payments results in cost savings for both industry groups. CONCLUSION: The results of this evaluation indicate that public health strategies to enhance the uptake of Q fever vaccine among high-risk workers potentially provides excellent value for the money invested.