What does the value of modern medicine say about the $50,000 per quality-adjusted life-year decision rule?

BACKGROUND:: In the United States, $50,000 per Quality-Adjusted Life-Year (QALY) is a decision rule that is often used to guide interpretation of cost-effectiveness analyses. However, many investigators have questioned the scientific basis of this rule, and it has not been updated. METHODS:: We used 2 separate approaches to investigate whether the $50,000 per QALY rule is consistent with current resource allocation decisions. To infer a lower bound for the decision rule, we estimated the incremental cost-effectiveness of recent (2003) versus pre-ĝ€"modern eraĝ€" (1950) medical care in the United States. To infer an upper bound for the decision rule, we estimated the incremental cost-effectiveness of unsubsidized health insurance versus self-pay for nonelderly adults (ages 21ĝ€"64) without health insurance. We discounted both costs and benefits, following recommendations of the Panel on Cost-Effectiveness in Health and Medicine. RESULTS:: Our base case analyses suggest that plausible lower and upper bounds for a cost-effectiveness decision rule are $183,000 per life-year and $264,000 per life-year, respectively. Our sensitivity analyses widen the plausible range (between $95,000 per life-year saved and $264,000 per life-year saved when we considered only health caree, and between $109,000 per QALY saved and $297,000 per QALY saved when we considered health care 1/4s impact on quality as well as quantity of life) but it remained substantially higher than $50,000 per QALY. CONCLUSIONS:: It is very unlikely that $50,000 per QALY is consistent with societal preferences in the United States.