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Payers often need to balance their need to cut costs by limiting coverage for certain diagnostic or therapeutic interventions with the image they must present to the public, their secondary constituents, and consumers: that of an organization that is primarily concerned with the medical well-being of their clients, rather than their own fiscal health. The federal government, in the form of Medicare and Medicaid, shares the same concerns of private payers.19

TABLE 11.6. A framework on how to apply cost-effectiveness data.

Category

Consideration

Comment

Treatment A is more effective and saves money compared with treatment B

Incremental cost-effectiveness of treatment A $0-$50,000

Incremental cost-effectiveness of treatment A $50,000-$100,000

Incremental cost-effectiveness of treatment A more than $100,000

Use treatment A

Use treatment A, as likely appropriate use of societal resources

Consider treatment A

Do not use treatment A

Hypofractionated (single-dose) radiation for bone metastases vs. multiple dose schemes32 PET scans before thoracotomy prevent 21% of futile thoracotomies26

Several widely used interventions fall here: —Guideline-based pain management vs.

oncology-based care55 —Adjuvant therapy for breast cancer —Adjuvant therapy for colon cancer —Stem cell transplantation vs. melphalan and prednisone for myeloma patients under 6556

Routine preoperative head CT (vs. none) for resectable lung cancer with no evidence of CNS disease57

Breast cancer screening (vs. none) in women older than 7558

Several widely used interventions fall here: —Bisphosphonates for breast and myeloma cancer59

—Selective 5-HT3 antagonists for antiemesis

(reviewed by Earle et al.54) —Radiotherapy boost to whole breast radiation as part of primary therapy60 —Trastuzamab for metastatic breast cancer61

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