Reconciling ACEA and MCDA: Is There a Way Forward for  Measuring Cost-Effectiveness in the U.S. Healthcare Setting?

Abstract Background The ISPOR Special Task Force (STF) on US Value Assessment Frameworks. The STF was agnostic about exactly how to implement the quality-adjusted life year (QALY) as the denominator in the overall cost-effectiveness metric of the cost-per-QALY gained as a starting point in their deliberations on the issue of including a new technology in the health plan benefit. The STF offered two major alternative approaches—augmented cost-effectiveness analysis (ACEA) and MCDA—while emphasizing the need to apply either a willingness-to-pay (WTP) or opportunity cost threshold rule to operationalize the inclusion decision.Methods The MCDA model uses the multi-attribute utility function. The ACEA model is based on the expected utility theory. In both ACEA and MCDA models, value trade-offs are derived in a hierarchical model with two high-level objectives which measure overall health gain separately from financial attributes affecting consumption.ResultsEven though value trade-offs can be elicited or revealed without considering budget constraints, we demonstrate that they can be used similarly to willingness-to-pay-based cost-effectiveness thresholds for resource allocation decisions. The consideration of how costs of medical technology, income, and severity of disease affect value trade-offs demonstrates, however, that reconciling decisions in ACEA and MCDA requires that health and consumption are either complements or independent attributes. ConclusionsWe conclude that value trade-offs derived either from ACEA or MCDA move similarly with changes in main factors considered by enrollees and decision makers—costs of the medical technology, income, and severity of disease. Consequently, this complementarity between health and consumption is a necessary condition for reconciling ACEA and MCDA.