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QALY saved to $16,000. If the model includes no discounting for either costs or health benefits, the cost per QALY saved (compared to case 1) is approximately $19,000 (see Cases 10 and 11). The committee reiterates, however, that both costs and benefits should be discounted.

An Idealized Scenario

The committee believes that the model it recommends can and should have far more utility beyond informing research and development priority considerations. For example, a policymaker might want to evaluate and inform decisions about the value of investments in new vaccine delivery programs. Such a policymaker might also wish to evaluate those options in an idealized scenario. Therefore, the committee offers several examples, using the Vaccine X scenarios described above, of results obtained in the idealized scenario; that is, vaccines against disease X-1 through X-9 have just become available, they are all 100% effective, and there is a means to ensure that the entire target population is vaccinated immediately. The following discussion illustrates results that might be important if there is now a desire to find out the cost-effectiveness of an investment in a vaccine program against one of these nine diseases, if that program were to begin today. Because the model includes discounting for both costs and benefits, components of the model with a time factor are particularly affected by this change in analysis.

The cost-effectiveness ratios for vaccines X-1 through X-9 in the idealized scenario change in some fairly predictable ways. Vaccine strategies appear more cost-effective when analyzing this “idealized scenario” compared to the primary analysis reported by the committee (less-than-perfect utilization and efficacy, including development costs and time until program is stabilized). The denominator (health benefits) is higher (approximately two-fold) compared to the standard analysis in every case. The factors responsible for this are the positive change by increasing utilization and effectiveness and the absence of the negative impact of discounting the health benefits during the 12 years until the vaccine program is fully implemented (7 years for vaccine licensure and another 5 years for vaccine use to stabilize).

The numerator of the cost-effectiveness ratio is changed in the idealized scenario in several ways, and not always in ways that will be intuitively obvious. Costs for vaccine development ($7,200,000 for these vaccines) are zero in this analysis. Delivery costs increase in the idealized scenario because utilization is 100% and, therefore, 10% more vaccine needs to be purchased. Delivery costs are also increased because they do not need to be discounted to account for the time for vaccine licensure and for usage to stabilize. The cost of care saved with a vaccine strategy is higher in the idealized scenario because more people experience health benefits due to higher efficacy and utilization. In addition, the discounting is not applied for the 12-year lag required for licensure and for usage to stabilize. The net costs can be higher or lower in this scenario compared to the

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