The Role of Cost-Effectiveness in U.S. Vaccination Policy
Cet article plaide pour l'importance de l'analyse du rapport coût-efficacité de chaque politique de vaccination menée aux Etats-Unis
Vaccination policy is driven by several factors, including vaccine safety and efficacy, avertable disease burden, acceptability, and societal value. One measure of value is an intervention's cost-effectiveness, defined as the additional cost required per additional unit of health benefit produced as compared with the next-most-effective alternative. It is important to differentiate cost-effectiveness (value for money) from affordability (financial resources required); indeed, interventions with high value may not always be affordable. Although information on the cost-effectiveness of health interventions is increasingly being used in health policy globally, the extent to which this information influences decisions varies by country. For example, the governments in Britain and Australia explicitly and routinely incorporate findings from cost-effectiveness analyses into coverage and reimbursement decisions; in contrast, in the United States, it has been essentially taboo for anyone in the public sector to refer explicitly to cost as a factor in health decisions. One exception is the Advisory Committee on Immunization Practices (ACIP), an independent expert advisory board that formally includes cost-effectiveness among the types of evidence it considers when making vaccine-policy recommendations to the Centers for Disease Control and Prevention (CDC). The ACIP strives to be transparent and balanced, inviting perspectives from stakeholders ranging from scientists to patient groups, and tries to harmonize its recommendations with those of professional organizations, such as the American Academy of Family Physicians and the American Academy of Pediatrics. Historically, ACIP recommendations have influenced coverage decisions by both private and public insurers. Through a separate process, the ACIP also determines what vaccines are to be covered by the federal Vaccines for Children (VFC) program, which covers children who are Medicaid-eligible, uninsured or underinsured, or American Indians or Alaska natives up to the age of 18. With nearly 50% of U.S. children eligible for VFC coverage,1 the ACIP faces dual pressures: it must maximize underserved children's access to vaccines while selecting vaccines that provide the most bang for the buck. This pressure will increase with the rollout of the Affordable Care Act, which mandates coverage of all ACIP-recommended childhood immunizations. With low cost and high efficacy, many vaccines are estimated to be cost-saving — the up-front expenditure for vaccination is entirely offset by costs averted through disease prevention. However, newly licensed and expensive vaccines, such as those against human papillomavirus (HPV, the virus causally linked to cervical cancer) and meningococcal disease, are being considered for use in ways that raise questions regarding their overall public health value as estimated in cost-effectiveness analyses.