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Cost Effectiveness Analysis in Health economics 


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Slide 1: Center for Prevention and Health Services ISSUEBrief An Employer Decision Support Tool This issue brief summarizes information presented at Cost-Effectiveness Analysis: An Employer Decision Support Tool, a web-based seminar at the National Business Group on Health sponsored by the Agency for Healthcare Research and Quality. Statistics and figures that are not annotated with a source were presented by the speakers. A glossary of italicized terms and a bibliography of additional cost-effectiveness resources are listed at the end of the brief. August 2004 Cost-Effectiveness Analysis: Introduction Table of Contents: Introduction Cost-Effectiveness Analysis Basics Why Employers Use CEA Common Applications S t r ategic Implicat i o n s Practical Examples S t r ategic Tips for Interpreting CEA Sample Abstract Case Studies Conclusion Glossary Resources References 1 2 3 4 6 9 10 11 12 14 15 17 19 Large employers face a challenging future in managing health care benefits. Managers have many program and coverage options, but are limited by budget constraints and data availability. Traditionally, decision-makers have used return on investment calculations to help guide their investment choices, but they can also consider another tool — cost-effectiveness analysis. Cost-effectiveness analysis (CEA) is a method of financial evaluation that has gained prominence within academic and policy communities in the last 20 years. But this methodology can also have business applications as a decision support tool. This issue brief explains cost-effectiveness analysis, outlines its usefulness to employers, demonstrates how cost-effectiveness relates to corporate strategy, and gives examples of its applications in health benefits decisions.
Slide 2: August 2004 ISSUEBrief 2 Cost-Effectiveness Analysis Basics Cost-effectiveness analysis is a specific type of economic analysis in which all costs are related to a single, common effect. Decision makers can use it to compare different resource allocation options in like terms. A general misconception is that CEA is merely a means of finding the least expensive alternative or getting the “most bang for the buck.” In reality, CEA is a comparison tool; it will not always indicate a clear choice, but it will evaluate options quantitatively and objectively based on a defined model. CEA was designed to evaluate health care interventions, but the methodology can be used for nonhealth economic applications as well. It can compare any resource allocation with measurable outcomes to any other resource allocation with measurable outcomes. Conducting, Evaluating, and Using Analyses Increasing numbers of analyses are conducted in academia or research organizations and published in peer-reviewed journals. Government organizations use analyses to help shape public policy. Health insurers use CEAs to determine which kinds of health interventions to cover. There is a growing body of work that quantitatively compares the health returned on different interventions employers cover in their benefits packages. As employers are increasingly asking providers to practice evidence-based medicine, they can direct this trend by evaluating and acting on evidence, or by holding health plans and consultants accountable for evaluation and action. Cost-effectiveness analysis, or CEA, is a comparison tool to help evaluate choices. It will not always indicate a clear choice, but it will evaluate options quantitatively based on a defined model. For managers, CEA provides peer-reviewed evidence for decision support.
Slide 3: 3 ISSUEBrief August 2004 Cost-Effectiveness Ratio The cost-effectiveness ratio is simply the sum of all benefits divided by the sum of all costs. This is comparable to a return on investment calculation; however, the benefits are not measured in terms of just dollars, but in a ratio that incorporates both health outcomes and dollars. Since healthier employees are more productive, improved outcomes actually do translate into dollars. But it is important to keep these values separate, so a decision maker can understand what kind of health benefit is returned on the investment. For instance, three investment choices could have cost-effectiveness ratios of Cost-Effectiveness Ratio = $10,000/premature birth avoided, $20,000/workplace injury prevented, or $30,000/life year gained. The (All benefits) decision maker must then choose the health intervention (All costs) that is right in terms of budget and population health goals. CEAs compare several program strategies and then rank them by of cost-effectiveness ratios. An analysis of two screening interventions might show you that one costs $10,000/life year gained while the other costs $40,000/life year gained. The first intervention requires monthly screening and the second requires biannual screening. Realizing that compliance is a greater problem with monthly screening, the decision maker would have to implement the most appropriate coverage strategy for the population in question. Sometimes, the analysis compares to baseline options such as “do nothing” or “usual care.” Both are valid strategic options. Why Employers Use CEA Cost-effectiveness analysis: ✓ Supports objective decision making: Decision makers can consider options in a comparable and objective way that provides support for the final decision. ✓ Brings clarity to data sources and outcomes: CEA evaluates options in similar terms to avoid “comparing apples to oranges.”
Slide 4: August 2004 ISSUEBrief 4 ✓ Allows for strategic review of organizations: CEA might justify some operational centers operating at a loss to increase overall return on investment, employee health, or both. ✓ Can be used in a host of operational and benefits areas including: • Screening coverage • Pharmacy • Strategic Planning • Labor Relations • Disease Management • Disability Management • Wellness and Prevention Programs ✓ Presents evidence that can help gain support for changes in benefits plans or employer-sponsored health programs. Common Applications Evaluating Program Options In the case of health screening, it is often difficult to determine the most cost-effective frequency. Too frequent screening has high cost and possibly limited health benefits, while too infrequent screening has low cost, but poor health outcomes. Determining appropriate screening frequencies is a useful application of cost-effectiveness analysis. The following table taken from an analysis on cervical cancer screening shows that life years are saved at a relatively low cost in the first comparison (screening versus no screening), but at a very high cost in the second comparison (the marginal cost and benefit of decreasing the interval between screenings). Typically, an intervention that costs less than $30,000/life year gained is considered cost-effective medicine. Based on this analysis, cervical cancer screening every four years is a relatively cost-effective benefit to cover. It is certainly more cost-effective than screening every three years.
Slide 5: 5 ISSUEBrief August 2004 Table 1: Example Data from an Analysis of Cervical Cancer Screening Frequency Screen every four years vs. no screening Screen every three years vs. screen every four years 1.6 0.2 $91 $184,528 Life expectancy increase, days Life expectancy increase, days (discounted 5%)* Cost increase, dollars (discounted 5%) Cost per life year gained 93.8 9.5 $264 $10,101 Source: E d dy D.M. “Screening for Cervical Cancer,” Annals of Internal Medicine 1990; 113: 214-226. * Annual discount rat e adjust future costs and benefits to account for time preference and opportunity cost. Justifying Program Implementation When building a case to justify the use of funds, strong data is often compelling evidence. Cost-effectiveness analyses can be used to support qualitative arguments for health interventions. The following table examines a depression treatment improvement program. Treatment facilities in the study were offered training for practice leaders and nurses, enhanced educational and assessment resources, and trained psychotherapists for patient follow-ups. Not only was the intervention relatively cost-effective, but it also increased attendance in workers suffering from depression. Table 2: Example Data from an Analysis of a Depression Treatment Improvement Program Quality improvement program vs. usual care Quality-adjusted life year increase Cost increase Cost per quality adjusted life year Days of employment increase 0.0226 $485 $21,460 20.9 Source: Schoenbaum M. et al. “The Cost-effectiveness of Practice-Initiated Quality Improvement for Depression: Results from a Randomized, Controlled Trial,” JAMA 2001; 286: 1325-1330.
Slide 6: August 2004 ISSUEBrief 6 Cost-effectiveness analysis can be a valuable source of information and data for employers. Most employers are not in the business of conducting analyses; however, it is reasonable to expect carriers to rationalize and explain different coverage options in terms of costeffectiveness. Strategic Implications A System View Because cost-effectiveness analysis examines a comprehensive set of costs and outcomes, it is important to avoid narrow strategy that only considers implication for individual department programs or cost centers. Managers can examine all parts of the health benefits system to determine if financial losses in one area are recouped in another. For example, dollars spent in richer benefit reimbursement might increase utilization and avoid future costs of treatment. The diagram below presents a system view of employer-sponsored health care. INPUTS • Diverse Workforce • Work Environment • HR & Benefits • Vendors & Providers Health Behavior Symptoms & Disease Diagnosis & Treatment Benefit Reimbursement OUTPUTS • Health Stat u s • Productivity • Health Care Costs • Retention • Disability/Absenteeism • Presenteeism Source: Michael Thompson, PricewaterhouseCoopers
Slide 7: 7 ISSUEBrief August 2004 Employers can use cost-effectiveness analysis to review each system component and choose the best strategy to optimize utilization, improve outcomes, and encourage healthier and more beneficial lifestyle choices. Strategic Readiness Unconventional methods like cost-effectiveness analysis are not an ideal fit for all organizations. Every company that provides health benefits has a different strategy for plan design and analysis. In some organizations, an attempt to incorporate costeffectiveness analysis into decision making might be resisted or rejected altogether. To avoid such a misstep, assessment of corporate culture is necessary. The diagram below shows health care strategy as a continuum. Organizations that are more access-oriented analyze specific health care costs and delegate cost reduction responsibility to their carriers. Goals focus on controlling costs so that employers can continue to offer health care access through employee benefits. Organizations that are more system-oriented involve employees, employers, and health plans in dialogue about whole health management. Shared goals focus on increasing health and changing utilization patterns to control future costs. Access Oriented Approach Aware & Inactive Employee Benefit Health Care Access & Cost Delegated Accountability Health Care Strategy Leadership Culture Focus Health Plans Source: Michael Thompson, PricewaterhouseCoopers System Oriented Approach E n g age & Enable Share Responsibility Health & Performance Integrated & Optimized
Slide 8: August 2004 ISSUEBrief 8 To assess where large employers believe they lie on this continuum, a number of benefits, health, and human resources professionals rated their organizations on a scale from 1 (mostly access-oriented) to 5 (mostly system-oriented) for the four component areas as well as overall approach.
Slide 9: 9 ISSUEBrief August 2004 Practical Examples Pharmaceutical Formularies Employers can use CEA to compare specific drugs on their formularies or evaluate the cost-effectiveness of their entire pharmaceutical benefits packages. In comparing specific drugs, such as high-cost statins and beta-blockers, benefits managers address not only cost differences between brand name and generic, but disparities in effectiveness as well. This might include examining effectiveness per dose cost. For example, a particular statin may be the least expensive option per dose, but comparing it to other options in terms of cost and ability to reduce LDL levels may prove it is a less cost-effective choice (see Table 3). In analyzing an entire pharmacy program, employers determine costs for particular drugs in terms of tiers and responsibility. The recent trend has been for employers to shift more of the costs of medications to employees through higher co-pays or co-insurance, but this may not always be the most cost-effective long-term solution. Abandoning this strategy may create a financial loss on some prescriptions, but overall cost savings could be substantial if absenteeism, presenteeism, and disability are reduced in the process. Companies might also consider how they will price brand name drugs versus generics, especially for medications that have proven to be similar in safety and effectiveness. Table 3: Example Data from a Comparison of Six Statins Daily Dose (% LDL reduction/dose cost) Statin Statin A Statin B Statin C Statin D Statin E Statin F 5 mg N/A N/A N/A N/A 45%/$2.22 26%/$1.63 10 mg 39%/$2.04 N/A 21%/$0.96 22%/$2.50 52%/$2.22 30%/$2.18 20 mg 43%/$3.07 22%/$1.56 27%/$1.11 32%/$2.52 55%/$2.22 30%/$2.18 40 mg 50%/$3.07 25%/$1.56 31%/$1.97 34%/$3.07 63%/$2.22 41%/$3.72 80 mg 60%/$3.07 35%/$1.97 N/A 37%/$3.76 N/A 47%/$3.73 Source: Michael Jacobs, Mercer Human Resource Consulting If decision makers were only looking for the lowest cost alternatives, they might select 10mg of statin C. However, 40mg of statin E is the most cost-effective option. This dosage has the highest LDL reduction for the cost associated with it. Benefit managers can consider this information in making formulary decisions; however, this may not be the most favorable option when factors such as employee health characteristics, unions, and other issues weigh into the choice.
Slide 10: August 2004 ISSUEBrief 10 Disease Management and Treatment Cost-effectiveness analysis is a useful tool in developing and evaluating disease management and treatment programs. It allows employers to determine objectively what services to cover, for which populations, and how often. Employers, providers, and insurers will normally seek the dominant choice — that choice which has lower costs and better outcomes than other choices in the same situation. Often, lower costs may be realized at the expense of outcomes, or better outcomes achieved at unacceptable costs. In such cases, cost-effectiveness analysis can compare options and lead to smarter choices. Employers and health plans can also use CEA to determine limits on coverage — for what age, for which populations, how often, and other restrictions. A helpful reference for such decisions may be the United States Preventive Services Task Force recommendations for clinical services. The Task Force critically examines published research, including costeffectiveness analyses, to determine the practical feasibility of health interventions recommended in the literature. Strategic Tips for Interpreting a CEA ✓ Consider perspective. Which parties are incurring costs and which parties are receiving benefits? Many studies take a broad societal perspective; they are usually not written for an employer audience. ✓ Identify the strategies under comparison. Does the study compare different alternatives (treat using drug A vs. treat using drug B) or examine incremental changes in the same health intervention (screen every two years vs. screen every four years)? ✓ Be aware of the analytic horizon. When are costs incurred and when are benefits received? Most studies use a 3-5% annual discount rate to adjust both costs and benefits to a present value, but if a benefit is not received until 10 years after an intervention begins, this is important information to note. ✓ Analyze all stated assumptions. Are the assumptions built into the economic model clearly defined, and are they valid for employers? ✓ Examine the sensitivity analysis. How do differences in data inputs affect the outcome? Think how this relates to the health characteristics of your employee population. ✓ Understand all metrics. How did the author present the cost-effectiveness ratio? Most studies measure the costs of increased quality of life ($/quality adjusted life year gained), disability prevented ($/disability adjusted life year prevented) or of life saved ($/life year gained). A study that measures quality adjusted life years is called a cost-utility analysis, a specific type of CEA.
Slide 11: 11 ISSUEBrief August 2004 Sample Abstract The following abstract from a study published in the Journal of the American Medical Association shows that nicotine patch therapy, in conjunction with physician counseling, is a cost-effective approach to smoking cessation. This is an example of information in published CEAs that can support coverage decisions and justify health improvement programs. Cost-effectiveness of the transdermal nicotine patch as an adjunct to physicians' smoking cessation counseling K. Fiscella and P. Franks Primary Care Institute, Highland Hospital, Rochester, NY, USA. OBJECTIVE: To determine the incremental cost-effectiveness of the transdermal nicotine patch. DESIGN: Decision analytic model that evaluated the incremental cost-effectiveness of the addition of the nicotine patch to smoking cessation counseling. Costs were based on physician time and the retail cost of the nicotine patch, and benefits were based on quality-adjusted life years (QALYs) saved. PATIENTS: Male and female smokers aged 25 to 69 years receiving primary care. INTERVENTION: Addition of the nicotine patch to physician-based smoking cessation counseling. MAIN OUTCOME MEASURE: Costs (1995 dollars) per QALYs saved discounted by 3% annually. RESULTS: The use of the patch produced one additional lifetime quitter at a cost of $7,332. The incremental cost effectiveness of the nicotine patch by age group ranged from $4,390 to $10,943 per QALY for men and $4,955 to $6,983 per QALY for women. A clinical strategy involving limiting prescription renewals to patients successfully abstaining for the first two weeks improved the cost-effectiveness of the patch by 25%. CONCLUSIONS: The findings provide support both for the routine use of the nicotine patch as an adjunct to physicians’ smoking cessation counseling and for health insurance coverage of nicotine patch therapy. From JAMA 1996; 275: 1247-1251.
Slide 12: August 2004 ISSUEBrief 12 Case Studies Case Study 1 — A Large Manufacturing Company Redefines Pharmacy Benefits This global manufacturer of document management systems operates in more than 130 countries with more than 35,000 employees worldwide and 27,000 employees in the United States. The company’s services include document management and mail security products and systems. In 2001, this company took a bold step to stem the rising costs of its health care benefits. In analyzing where costs were the highest, the company found that those employees with chronic conditions such as diabetes and asthma incurred the highest cost. Startlingly, they found that many of these individuals did not refill their prescriptions properly because of the high co-insurance price. Using predictive modeling to come to this conclusion and hoping that increasing compliance would lower costs, the company’s medical director restructured its pricing tiers for pharmaceuticals. The organization implemented a new multi-tiered system in which generics and those drugs targeting chronic conditions such as diabetes and asthma (including prescriptions for inhalers and insulin) would require copays as low as 10% of the total cost. After implementing this new pricing system at the end of 2001, the company realized significant cost savings. Lower co-payments for the two chronic conditions had increased compliance. Cost savings also came from fewer emergency room visits and hospital admissions due to better personal disease management. Median medical costs for each employee with diabetes fell 12%, and the company saved $1,000 per employee. For those with asthma, median medical costs dropped 15% with a savings of $900 per person. The company predicts savings estimated at $1 million in 2004 and even more in future years. By using data-driven, total health strategy, a change that seemed costly has proven to be cost-effective.
Slide 13: 13 ISSUEBrief August 2004 Case Study 2 — A Large Airline Reexamines Health Benefits Strategy This airline has more than 3,000 daily departures, flies to 38 states including the District of Columbia and 41 sites internationally, and employs more than 28,000 individuals. The organization recently faced several challenges: • • • • Negotiating with nine unions twice Filing for bankruptcy Outsourcing health care administration, which had been done internally Consolidating 23 health plans down to a single one During this period, many employees expressed discontent about plan changes, coverage decisions, and health care access. New executive leaders decided to fundamentally change health benefit strategy, including the use of cost-effectiveness analysis in plan design decisions. The company took the following actions: • • • Requesting reports from vendors to assess health plan information Forming a collaborative union management group Establishing an internal plan performance group, including both finance and labor relations staff, to review health care data sets The airline is currently pursuing strategy that will facilitate positive health plan changes, made in collaboration with its unions and its health insurance carrier. Although it still faces serious financial challenges, the airline is now examining its health plan through data-driven discussions on whole health management and including cost-effectiveness analyses in health benefit strategy.
Slide 14: August 2004 ISSUEBrief 14 Conclusion Cost-effectiveness analyses provide quantitative support to managerial decision-making. Budget requests and in-house proposals for health program change can be more convincing with the addition of cost-effectiveness data. Asking vendors and consultants to support their products and proposals with cost-effectiveness data assures managers they are purchasing based on value. Organizations use these approaches and others because they recognize that objective economic analyses such as CEA are sound corporate strategy.
Slide 15: 15 ISSUEBrief August 2004 Glossary of Cost-effectiveness Terms Many definitions are from Prevention Effectiveness: A Guide to Decision Analysis and Economic Evaluation. See references for more information. ✓ Agency for Healthcare Research and Quality (AHRQ): A federal agency with the mission to improve the quality, safety, efficiency, and effectiveness of health care for all Americans. ✓ Analytic horizon: The time period over which the costs and benefits of health outcomes that occur as the result of an intervention are considered. ✓ Annual discount rate: Adjustment made to the value of future costs and benefits to account for time preference and opportunity cost. ✓ Approach, access-oriented: Providing employees access to the health system through their benefits packages and managing costs by analyzing data for each covered benefit. ✓ Approach, system-oriented: Promoting employee health through an interrelated system of programs and benefits and managing costs with the knowledge that investment in one program or benefit may be offset by savings in others. ✓ Cost-effectiveness: The minimum cost for a given benefit, the maximum benefit for a given cost, or a balance of low costs and high benefits that has maximum utility. ✓ Cost-effectiveness analysis (CEA): An economic analysis in which all costs are related to a single, common effect, usually in terms of cost expended per outcome achieved. ✓ Cost-effectiveness ratio: The ratio of total costs of investment to total accrued benefits, in terms of both dollars and benefit value. ✓ Cost-utility analysis (CUA): A type of cost-effectiveness analysis in which benefits are expressed in terms of cost per QALY gained. ✓ Dominant choice: Choice with both lower costs and higher benefits than all other options.
Slide 16: August 2004 ISSUEBrief 16 ✓ Life year gained: An outcome measure that incorporates only duration of survival, not quality of life. ✓ Quality adjusted life year (QALY): A frequently used outcome measure that incorporates the quality and desirability of a health state with the duration of survival; quality of life is integrated with length of life using a multiplicative formula. ✓ Return on investment (ROI): The ratio of capital investment in dollars to accrued return in dollars. ✓ Sensitivity analysis: Mathematical calculations that isolate factors involved in an analysis to indicate the degree of influence each factor has on the outcome of the analysis. ✓ Societal perspective: Analytic view that includes all benefits of a program regardless of who receives them and all costs regardless of who pays them.
Slide 17: 17 ISSUEBrief August 2004 Web Resources ✓ Agency for Healthcare Research and Quality AHRQ is a leader in advancing the science of cost-effectiveness analysis in health care. This page explains current initiatives in this discipline, including the Research Initiative in Clinical Economics. ✓ United States Preventive Services Task Force USPSTF is an independent panel of experts in primary care and prevention that systematically reviews the evidence of and develops recommendations for clinical preventive services. ✓ National Health Service Centre for Reviews and Dissemination The United Kingdom’s National Health Service maintains databases of economic evaluations and health technology assessments at the University of York. ✓ Harvard Center for Risk Analysis CEA Registry The Harvard School of Public Health maintained a reference list of cost-effectiveness analyses from 1976-2001. It does not include more current studies, but serves as a useful historical database.
Slide 18: August 2004 ISSUEBrief 18 Print Resources ✓ Haddix A., Teutsch S., Corso P. Prevention Effectiveness: A Guide to Decision Analysis and Economic Evaluation. New York: Oxford University Press, 2003. Officials from AHRQ and CDC collaborated with leading academics on this text. It gives in-depth explanations of cost-effectiveness analysis beginning with theory and concluding with application. ✓ Gold M. R., Siegel J. E., Russell L. B., Weinstein M.C. Cost-Effectiveness in Health and Medicine. New York: Oxford University Press, 1996. This report details the recommendations of the Panel on Cost-Effectiveness in Health in Medicine, a committee of researchers convened by the United States Public Health Service to establish guidelines for analyses. The findings of the Panel are also outlined in three articles in the Journal of the American Medical Association (JAMA 1996; 276: 1172-1177, 1253-1258, and 1339-1341). ✓ Schoenbaum M., Unutzer J., Sherbourne C., Duan N., Rubenstein L.V., Miranda J., Meredith L.S., Carney M.F. and Wells K. “The Cost-effectiveness of Practice-Initiated Quality Improvement for Depression: Results from a Randomized, Controlled Trial,” JAMA 2001; 286: 1325-1330. Dr. Schoenbaum, a speaker at the May 2004 web event, conducted an analysis of a quality improvement program for depression treatment (see Page 3, Table 2 ). His publication demonstrates the usefulness of cost-effectiveness analysis as an evaluative tool. ✓ Neumann P.J. “Why Don’t Americans Use Cost-Effectiveness Analysis?” American Journal of Managed Care 2004; 10: 308-312. Neumann presents a short editorial explaining resistance to cost-effectiveness analysis in the United States. He surmises the positions of different stakeholder groups toward CEA and offers thoughts to help decision makers better use CEA in the future.
Slide 19: 19 ISSUEBrief August 2004 References ✓ Fuhrmans V. “A Radical Prescription.” Wall Street Journal, May 10, 2004. ✓ Haddix A. et al. “Prevention Effectiveness: A Guide to Decision Analysis and Economic Evaluation.” New York, NY: Oxford University Press, 2003. ✓ Fiscella K. and Franks P. “Cost-effectiveness of the transdermal nicotine patch as an adjunct to physicians’ smoking cessation counseling.” JAMA 1996; 275: 1247-1251.
Slide 20: Center for Prevention ISSUEBrief and Health August 2004 Services Cost-Effectiveness Analysis: An Employer Decision Support Tool Written by: Ian Dixon and Andrew Lundeen, National Business Group on Health About the Center for Prevention and Health Services (CPHS) The Center houses the Business Group’s projects and resources that relate to the delive ry of preventive and other health services through employe r - s p o n s o re health plans and work s i t e d programs. Through the Center, employers can find practical toolkits to address pre ve n t i ve health and health promotion issues at the worksite. Em p l oyers will find current information and recommendations from federal agencies and professional associations, model programs from other employers, and the latest clinical and health services research results. In addition, the Center provides opportunities for employer participation in teleconferences and in-person solutions workshops. Currently, the Center has initiatives in racial and ethnic disparities in health and health care, terrorism and public health emergency preparedness, maternal and child health, preventive services, health services research and quality, health and work performance, benefit design, and wellness programs. For more information, visit vention/index.cfm or contact Ron Finch, EdD, Director, at About the National Business Group on Health The National Business Group on Health, formerly the Washington Business Group on Health, is the national voice of large employers dedicated to finding innovative and forward-thinking solutions to the nation’s most important health care issues. The Business Group represents over 200 members, primarily Fortune 500 companies and large public sector employers, who provide health coverage for approximately 50 million U.S. workers, retirees, and their families. The Business Group fosters the development of a quality health care delivery system and treatments based on scientific evidence of effectiveness. The Business Group works with other organizations to promote patient safety and expand the use of technology assessment to ensure access to superior new technology and the elimination of ineffective technology. Helen Darling, President National Business Group on Health 50 F Street NW, Suite 600 • Washington DC 20001 Phone (202) 628-9320 • Fax (202) 628-9244 •

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