Applying Cost-Effectiveness Thresholds to the Real World: Implications on Access for Medicare Beneficiaries

Continued concerns about rising healthcare costs have prompted renewed proposal for use of a single value threshold (eg, cost-effectiveness threshold or similar approaches) as the basis for setting coverage or payment policy.

We found that if Medicare Part B were to apply the cost-effectiveness thresholds utilized by the Institute for Clinical and Economic Review (ICER) as the basis for coverage policy, 62% to 93% of patients with serious, complex conditions would face access barriers to clinically important physician-administered treatments.