Current use and potential value of cost-effectiveness analysis in U.S. health care: The case of medicare national coverage determinations

This thesis was submitted for the degree of Doctor of Philosophy and awarded by Brunel University.There is a growing recognition that we cannot afford the provision of all new health care technologies, even those that are proven to be beneficial. This is increasingly true in the US, where health care spending is on an unsustainable upward trajectory. US health care spending is greatly in excess of that of other countries; however, with respect to key health metrics, the US health care system performs relatively poorly. Despite this, unlike many other developed countries economic evaluation, and more specifically cost effectiveness evidence, is used sparingly in the US health care system. Notably, the Centers for Medicare and Medicaid Services (CMS), administrators of the Medicare programme, state that cost-effectiveness evidence is not relevant to coverage decisions for medical technology and interventions evaluated as part of National Coverage Determinations (NCDs). The empirical aspect of this thesis evaluates the current use and potential value of using cost-effectiveness evidence in CMS NCDs. A database was built using data obtained from NCD decision memoranda, the medical literature, a Medicare claims database, and Medicare reimbursement information. The findings of the empirical work show that, CMS’s stated position notwithstanding, cost-effectiveness evidence has been cited or discussed in a number of coverage decisions, and there is a statistically significant difference between positive and non-coverage decisions with respect to cost effectiveness. When controlling for factors likely to have an effect on coverage decisions, the availability of cost-effectiveness evidence is a statistically significant predictor of coverage. In addition, the quality of the supporting clinical evidence, the availability of alternative interventions, and the recency of the decision are statistically significant variables. Further, when hypothetically reallocating resources in accordance with cost-effectiveness substantial gains in aggregate health are estimated. It is shown that using cost-effectiveness to guide resource allocation has an effect on resource allocation across patient populations and types of technology

Developing A Framework For Civilian-Military Public Health Operations Involving Non-State Armed Groups

Introduction: The interface of military forces, civilian actors and non-state armed groups (NSAGs) during a public health emergency within an active conflict is a situation fraught with legal and ethical challenges not adequately addressed in established doctrine or international guidance documents. Ongoing public health crises in Yemen and Afghanistan represent the real-world consequences of threats to population health and security if these critical gaps are not addressed. Methods: A list of five diverse medical scenarios was developed as an initial attempt to produce a practical, historically-informed framework for use in future civilian-military (CIV-MIL) training events and guidance. Ten virtual interviews with experts from the humanitarian, US government and academic communities were conducted and qualitatively analyzed in order to identify overarching issues surrounding NSAGs and to solicit feedback on the proposed scenario framework. Results: Analysis of the interviews resulted in three broad areas of interest and concern surrounding NSAGs: 1. definitional challenges; 2. the value of historical precedence; 3. ethics and international humanitarian law. Patterns that were identified from discussion of the scenario framework include: 1. gaps in public health specific CIV-MIL training; 2. relationship building and trust; 3. critical feedback and assessment for each of the five specific scenarios. Discussion: The guidance documents within the CIV-MIL community surrounding NSAGs and public health emergencies should be revised with a focus on integration of the two concepts. Updates are required in order to ensure existing institutional knowledge and critical planning factors are captured and considered. The scenario framework was well-received and should be propagated among additional stakeholders in the humanitarian ecosystem for further examination and analysis, as well as included in future CIV-MIL humanitarian workshops and training events

NGOs, Soft Power, and Environmental Politics

This paper explores the connection between NGOs and the growing international environmental regime. It questions the role these groups have played in building international law, arguing that they use soft power to overcome the interests of states in negotiations. After providing background on the idea of soft power, the paper uses three case studies to demonstrate the argument: the Rio Declaration, the Montreal Protocol, and the Kyoto Protocol. The findings from these studies challenge realism and support a constructivist analysis of international regime-building

Monitoring Networked Applications With Incremental Quantile Estimation

Networked applications have software components that reside on different computers. Email, for example, has database, processing, and user interface components that can be distributed across a network and shared by users in different locations or work groups. End-to-end performance and reliability metrics describe the software quality experienced by these groups of users, taking into account all the software components in the pipeline. Each user produces only some of the data needed to understand the quality of the application for the group, so group performance metrics are obtained by combining summary statistics that each end computer periodically (and automatically) sends to a central server. The group quality metrics usually focus on medians and tail quantiles rather than on averages. Distributed quantile estimation is challenging, though, especially when passing large amounts of data around the network solely to compute quality metrics is undesirable. This paper describes an Incremental Quantile (IQ) estimation method that is designed for performance monitoring at arbitrary levels of network aggregation and time resolution when only a limited amount of data can be transferred. Applications to both real and simulated data are provided.Comment: This paper commented in: [arXiv:0708.0317], [arXiv:0708.0336], [arXiv:0708.0338]. Rejoinder in [arXiv:0708.0339]. Published at http://dx.doi.org/10.1214/088342306000000583 in the Statistical Science (http://www.imstat.org/sts/) by the Institute of Mathematical Statistics (http://www.imstat.org

Rejoinder: Monitoring Networked Applications With Incremental Quantile Estimation

Rejoinder: Monitoring Networked Applications With Incremental Quantile Estimation [arXiv:0708.0302]Comment: Published at http://dx.doi.org/10.1214/088342306000000592 in the Statistical Science (http://www.imstat.org/sts/) by the Institute of Mathematical Statistics (http://www.imstat.org

Preparing for the Looming Changes in Lease Accounting

Donald Rumsfeld famously stated, “There are known knowns. These are things we know that we know. There are known unknowns. That is to say, there are things that we know we don’t know. But there are also unknown unknowns. There are things we don’t know we don’t know.” Rumsfeld’s statement can be applied to our state of knowledge regarding the accounting for operating leases in the future. There is general agreement (that is, a “known known”) that new standards will require lessees to report most of the assets and related liabilities associated with operating leases on the balance sheet—a significant change from current off-balance-sheet reporting. A “known unknown” is the final form of the accounting standard, including the way leases will be classified (e.g., not operating, but what instead?), and the specific patterns of expense recognition for leases newly recognized on the balance sheet. The “unknown unknowns” can apply to lessee companies that do not yet understand the extent of the preparation and data gathering they face in order to be ready by the new standard’s effective date (whenever that proves to be)