2017 Sec 1 Green Book

A.

Bergevin

et al.

/ International

Journal

of Pediatric Otorhinolaryngology 79

(2015)

2090–2093

Table 1 Cost–benefit

figures

of mandatory

CMV

testing

for

infants who

fail

two

newborn

hearing

screenings

using

different model

assumptions.

Baseline model a

No

cochlear

implants

One

cochlear

implant

80%

of

newborns

on

public

avoided

avoided

insurance

2014

2015

2014

2015

2014

2015

2014

2015

Costs

setup

$4,000 $30,800 $7,260 $4,839

$4000

$4000

$4,000 $30,800 $7,260 $9,678

Program

administrative

$30,800 $7,260 $4,839

$30,800

$30,800

$30,800

$30,800 $7,260 $4,839

$30,800 $7,260 $9,678

Fixed

Screenings

$7260 $4839

$7260 $4839

$7260 $4839

treatment and monitoring

Antiviral

tests

costs

$46,899

$42,899

$46,899

$42,899

$46,899

$42,899

$57,348

$53,348

Total

Benefits

savings

$93,600

$93,600

$0

$0

$46,800

$46,800

$140,400

$140,400

Treatment

Benefits–costs

$46,691

$50,701

($46,899)

($42,899)

($99)

$3,901

$83,052

$87,052

a The

base model

chooses

values

near

the middle

of

the

ranges

provided

for

the

costs/benefits

for which we

have

ranges

and

uses

precise

estimates where

available.

those outlined

in

the fiscal note

incurred directly by

the Department of Health, screening costs are

the costs

to

the government incurred only by

Program setup & fixed administrative costs are

through Medicaid/CHIP

for the proportion of screening costs expected

to be publicly

funded, and antiviral

treatment and monitoring

tests are

likewise

those

patients who

are

publicly

funded

and that

elect child

to

undergo

those

procedures.

This model

assumes

one

child

covered

by Medicaid/CHIP

and

diagnosed with

CMV-related

the

hearing

loss

each

year,

takes

antivirals,

and

s/he would

have

needed

cochlear

implants without

the

intervention.

sensorineural

progressive

mimic

the

rate

nationwide

for

children

under

age

three.

It

also

SNHL.

A

targeted

approach

requires

CMV

testing

of

that

the

one

publicly

funded

patient

who

pursues

small

number

of

infants

per

year

as

compared

to

testing

assumes antiviral

a

therapy

will mitigate

hearing

loss

to

an

extent

that

s/

of

infants

if

a

universal

program was

implemented.

thousands

will

only

require

hearing

aids

rather

than

bilateral

cochlear

et

al.,

estimated

the

cost of

a

targeted CMV

screening

he

Williams

The model

shows

a

large

net

benefit.

the United Kingdom

[12] . They utilized data

from

implants.

program within

next

two

models

that

appear

in

Table

1

illustrate

the

national

hearing

screening

program

in

England

and

from

a

The

the

if,

under

the

same

set

of

assumptions,

no

cochlear

completed

study

using

saliva

swabs.

The

costs

of

difference implants avoided. is a net cost

recently screening estimated

are

avoided

or

only

a

single

implant

(unilateral)

is

time,

PCR

testing,

and this

treatment were approach would

calculated.

They

In the case where no cochlear

implants are avoided,

there

that

the

cost

for

be

$10,693

per

to

the government, and

in

the case of a

single cochlear

and

concluded

this

amount would be

favorable

compared

to

child other

avoided,

the

costs

and

benefits

essentially

cancel

each

screening

programs.

implant

other out. The final model considers how costs and benefits might differ if the number of publicly insured infants increases as individuals take advantage of their public insurance eligibility to avoid tax penalties for the uninsured or as increased numbers of individuals are eligible for public insurance under currently debated Medicaid expansion in Utah. This model considers the extreme scenario of 80% of infants on public insurance (using the high end of the Department of Health data on current eligibility). All other assumptions follow the base model. While this increases dramatically the public dollars paid for CMV screenings, it only increases the number of CMV-positive children that take VGC on public insurance from one to two children per year. At most it might mean that two children avoid cochlear implantation each year rather than one. The model above calculates the benefit if one of those two children would have had a single CI and the other would have been bilateral and both are able to avoid cochlear implantation. Overall, this model illustrates that the effect of increased public insurance is not as significant a factor in the calculation as the potential cost–savings if VGC treatment proves effective. In sum, we found the implementation of Utah’s hearing- targeted CMV screening program to have a net public benefit in three of the four cost–benefit scenarios we investigated. Only in the instance where no cochlear implant is avoided in a year does the program show a net public cost, albeit a modest one.

costs

per

child

determined

from

our

analysis

would

be

The

less

than

that

from

the Williams

et

al.,

study

although

a

much direct

comparison

is

difficult

given

the

different

health

care

of

the

cost

from

screening

and

treatment

of

the

systems. Much

infected

hearing

impaired cochlear

infants

will

come

from

congenitally

therapy

and

from

implantation.

Eighteen fourteen therapy.

antiviral months

since

implementation

of

this

approach,

eight

of

diagnosed

with

CMV

have

undergone

antiviral

infants

et

al.,

reported

one

child who

underwent

6 months

of

Kimberlin

therapy

requiring

cochlear

implantation

compared

to

three

VGC

who

underwent

6

week

VGC

therapy

requiring

this

children

the 12 month

follow up period

[10] . At

the 24

surgical procedure at

follow up period,

four children undergoing 6 months of VGC

month therapy requiring

required

cochlear

implantation

compared

to

six

children therapy.

the same procedure undergoing 6 weeks of VGC

that our cost–benefit estimates are overly generous as

It may be

a

minority

of

children

who

would

qualify

for

cochlear

only

in

the

United

States

actually

receive

them

[10] .

This that

implants

potential over-estimation however, is

likely offset by

the

fact

did

not

include

the

familial

and

educational

benefits law. Nor

of

early

we

that will

be

attributable

to

the Utah

did we

intervention

for

the

benefits

of

the

preventive

educational

program-

account

by

the

legislation.

Both

of

these

omissions make

ming mandated

analyses

conservative.

our

5. Conclusion

4. Discussion

results

support

a

possible

societal

savings

from

early only

Our

enormous

societal

costs

of

congenital

CMV

must

be

and the

treatment screening

of

CMV.

This

analysis

considers

identification

The

the

costs

incurred

from any early CMV

screening

impact

of

portion

of

the

program.

Overall,

the

balanced against

the

A

targeted

hearing

early

CMV

testing

approach was

a

suggest

that

there

is

reason

for

optimism

about

the

return

program.

results

investment

to

the

government

associated with

the Utah

law.

on

to

identify

infants

at

greatest

risk

to

develop

compromise

117