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.