Stirling Bryan, a professor of health economics at the University of Birmingham (U.K.) and a 2005-2006 recipient of the Commonwealth Fund's prestigious Harkness Fellowship in Health Care Policy, will spend the next academic year based at CHP/PCOR, carrying out a research project that will examine fundamental questions of how medical technology coverage decisions are made in the United States, how cost-effectiveness analysis is used (or not used) in those decisions, and how the decision-making process could be improved in the U.S. and the U.K.

Bryan said he looks forward not only to learning from his experiences in the United States, but to sharing his knowledge and perspective from the United Kingdom, where he last year completed a research project examining how the National Institute for Health and Clinical Excellence (NICE) makes coverage decisions for the U.K.'s national health system, and how cost-effectiveness analysis is incorporated into that process.

"I don't envision my role here as just taking away information," said Bryan, the second Harkness Fellow to be hosted at Stanford. "I also want to share information that people may find helpful. There seems to be a lot of interest in how things are done in the U.K."

That statement proved true at CHP/PCOR's Research in Progress Seminar on Aug. 24, when Bryan presented his findings from the U.K. and discussed plans for his research in the U.S. The session attracted a roomful of CHP/PCOR faculty, staff and guests, who asked a number of questions about the U.K.'s healthcare system, including how cost-effectiveness thresholds are arrived at (the threshold typically used by NICE is 30,000 UK £ per quality-adjusted life year); how drugs are priced (this is done through a system of price regulations); and how NICE appraises therapies that are not the most clinically effective in their class but are less expensive than other commonly used therapies (Bryan said such therapies are rarely reviewed by NICE, but he felt they should be).

In introducing Bryan, CHP/PCOR director Alan Garber said, "It's a privilege to have him working with us. He's a great fit for CHP/PCOR, and I'm sure we'll learn a great deal from him."

Bryan began his talk by saying that based on what he's learned, "the important issues for making coverage decisions are very different here than in the U.K." In fact, he said, "it seems the two countries are on completely different tracks."

He explained that in the U.K., advisory committees within NICE decide whether selected emerging therapies should be covered, and for which patients, based on a thorough evaluation that considers the therapy's clinical effectiveness, the availability of other remedies for the targeted condition, and the therapy's cost-effectiveness as measured in quality-adjusted life years (QALYs). Each committee has 28 members including doctors, nurses, managers, patient advocates, drug/medical industry representatives, and economists or statisticians.

For his two-year-long U.K. project, Bryan and his collaborators observed 14 NICE committee meetings and interviewed 30 committee members, seeking to understand how they made coverage decisions and how they viewed cost-effectiveness information. The researchers found that, on the whole, committee members valued the cost-effectiveness information and used it in making their coverage recommendations. In fact, Bryan said, "many of them were surprised at how valuable they found this information. They came in thinking, 'OK, I'm going to have to listen to these health economists,' but then they found it was truly helpful."

The researchers concluded that "cost-effectiveness information is an essential driver of coverage decisions at NICE." They also found that among British policymakers NICE was generally considered a positive development, promoting rational decisions about patients' access to new medical interventions.

Bryan's research also uncovered some common concerns among the NICE committee members: Some didn't fully understand cost-effectiveness analysis and felt that training in this area was needed. Others felt the committee had become too permissive, sometimes approving therapies that society could not afford in the long run. "In the U.K., we recognize that our resources are limited," Bryan said. "If we say that statins should be put in the water because they're so great, we're going to bankrupt our national health system."

In contrast, Bryan noted, "It seems that this notion of limits and constraints is not something Americans want to talk about." He said he was "struck" by U.S. policymakers' lack of interest in cost-effectiveness and their failure to acknowledge the role of costs in making coverage decisions.

That said, Bryan emphasized that he believes one system isn't necessarily better than the other. "I'm not here to tell everyone how wonderful our system (in the U.K.) is. It has its faults," he said, including pressures being felt and sacrifices being made at the local level as healthcare providers try to implement policy decisions made at the national level.

For his Harkness Fellowship project, Bryan is interviewing decision-makers at major U.S. health systems including Kaiser Permanente, the VA Health Sytem, and Medicare. He will also observe the meetings of key coverage decision-making bodies, including Medicare's Coverage Advisory Committee and Kaiser Permanente's Inter-regional New Technologies Committee.

Bryan said he will keep an open mind throughout his investigations, and acknowledges that he has much to learn about the U.S. healthcare system. "The great thing about this project is, I get to ask the naive questions because I'm not from here, so people expect me to ask them."