138 / 232
Utah
legislature
in
February,
2013
[11]
.
This
bill mandated
CMV
testing
of
newborns
under
three
weeks
of
age
who
fail
their
newborn
hearing
screen(s).
Utah
became
the
first
state
to
implement
this
targeted
hearing
loss
driven
testing
approach
for
CMV
diagnosis when
the
bill was
signed
into
law
in
June
2013.
Data
from
Utah’s
newborn
hearing
screening
program
show
that
during
the
first
year
of
implementation
of
the
law
89%
of
newborns underwent
the
two hearing
screens
and
that 63% of
the
children
who
failed
the
two
newborn
hearing
screens
were
screened
for CMV
(
n
= 244). Among
the
children
screened,
5%
(12
infants)
tested
positive
for
CMV.
Some
of
these
CMV
positive
infants were
found
to
have
normal
hearing
following
audiologic
evaluation.
The
enormous
potential
health
burden
of
congenital
CMV
suggests
that
it
is vital
that we assess
the benefits of early detection
relative
to
the potentially significant costs of early CMV
testing and
treatment.
To
date,
only
one
such
cost
analysis
has
been
done
and
the
authors
found
targeted
newborn
screening
in
the United
Kingdom
to
be
cost
effective
[12]
. Given
the
differences
in
health
insurance
in
the
United
Kingdom,
it
is
unclear
if
these
study
findings would
extrapolate
to
the
United
States.
As
other
states,
including Texas, Hawaii,
Illinois and Connecticut,
consider or have
recently
passed
similar
legislation,
there
is
a
need
to
perform
a
cost–benefit
analysis
to
inform
public
policy
in
the United
States.
This
analysis
uses
an
ex-ante
approach
and
a
governmental
accounting perspective
to assess
the projected costs and benefits of
the Utah
law.
2. Materials
and methods
2.1.
Determining
costs &
benefits
Costs
fell
cleanly
into
two
categories:
administrative
costs
and
medical
costs.
Administrative
costs
were
those
incurred
by
the
Department
of
Health
for
both
the
education
and
screening
components
of
the
program.
The
government
also
bears
the
medical
costs
for
those
affected
infants
covered
by
the
public
insurance programs
(CHIP & Medicaid). Medical costs
include both
the
CMV
screening
test
and
the
differential
cost
of
treatment
for
CMV-positive
infants.
Benefits were
narrowly
defined
as medical
costs
avoided
that would have
otherwise been
incurred had
there
not been
early
screening
and
intervention. Benefits
to
individuals,
families,
and
private
insurers were
not
considered
and
cases
of
CMV prevented
entirely
through
education
and prevention
efforts
were also not captured
in
this analysis. The analysis thus provides a
conservative estimate, as
societal and even governmental benefits
from
the
law
certainly
exceed what
is
captured
here.
2.2.
Quantifying
costs
and
benefits
Administrative costs were drawn
from
the
legislative fiscal note
accompanying
the original bill
[13]
. Department of Health officials
confirmed
the
fiscal
note
was
an
accurate
estimate
of
actual
program
costs. The figures used
in
the analysis
include a one-time
startup
cost
of
$4000
and
an
annual
ongoing
appropriation
of
$30,800
1
.
Calculating
medical
costs
and
cost
avoidance
(benefits)
required
calculating
the
number
of
estimated
screenings
each
year
as
well
as
the
rate
of
positive
screenings
that
would
be
referred
for
further
evaluation
and
treatment.
For
infants
who
tested
positive
but
who
were
found
to
have
normal
hearing
following
audiological
evaluation,
only
the
cost
of
their
screening
is
included
in
the
analysis.
Screening
costs
and
additional
treatment
costs
are
included
for
infants with
confirmed
hearing
loss
2
.
The
cost
of
the
screening
itself was
$66
per
infant
3
.
The analysis only considers
the costs
for
those children
likely
to
be
on
public
insurance
because
we
are
using
a
governmental
perspective.
We
estimated
the
proportion
of
publicly
insured
infants
using
a
range
of
values
and
varied
them
in
our
sensitivity
analysis
to
test
the
impact
of
our
assumptions
4
.
All
infants
with
confirmed
hearing
loss
will
incur
medical
treatment
costs.
This
analysis
considers
the
added
costs
to
the
government
per
patient
with
confirmed
congenital
CMV
and
a
diagnosis of sensorineural hearing
loss. Treatment of CMV-induced
hearing
loss will
likely be
identical
to other
types of hearing
loss
in
infants except
for
the prescription of antiviral medication and
tests
to monitor
the patient during
treatment
5
. The
cost data presented
here
represent
the
cost
to
the
provider without
any markup
for
profit margins and
include $4453
for
the antiviral medication
for 6
months
and
$385.63
for
testing. As
such
they may underestimate
the
costs
from
a
private
insurance
perspective
but may
overesti-
mate
the
costs
from
a
Medicaid
reimbursement
perspective.
Absent
the
ability
to
secure Medicaid
reimbursement
rates,
these
cost
data were
our
best
estimates.
We present different hypothetical models
that
include avoiding
cochlear
implantation
in
patients
treated with
antiviral
therapy.
Cochlear
implantation
is
one
of
the
most
costly
factors
in
the
analysis.
Cochlear
implants
cost
$47,800
per
year
($95,600
for
bilateral) whereas hearing aids are $2000;
thus, avoiding
implants
will
save
anywhere
from
$46,800
to
$93,600
per
patient
[5]
.
A
transparent
cost
benefit
analysis
must
include
several
iterations
of
the
analysis,
varying
the
assumptions
to
illustrate
how
sensitive
the
results
are
to
particular
choices made.
Because
most
costs
related
to newborn hearing
loss are
incurred
in
the first
year or
two of
life, no discounting
is necessary
for
this analysis as all
costs andbenefits occurmore or less in the present.Manyof the costs
and benefits that will accrue
in the
future are to
individuals,
families
and
educational
institutions
rather
than
to
the
government.
In our
estimation,
the
society-wide
benefits
of
early
detection
and
intervention
far
exceed
those
presented
here.
For
the
following
models, all calculations project
forward
two years
into
the program.
3. Results
The
initial model
presented
in
Table
1
provides
a
baseline.
It
assumes
that
the
rate of public
insurance
coverage
for
infants will
1
In
the
second
year
additional
funding was
given,
but
administrators
note
this
funding was
to
be used
exclusively
for
the
educational
component
of
the
law
and
was
thus
excluded
from
our
analysis, which
evaluates
the
screening
component
alone.
2
Of
these
9
CMV
positive
children,
5
had
confirmed
hearing
loss
after
further
testing. All of
these children are at
risk of developing more extensive hearing
loss
in
early
childhood
as
CMV
induced
hearing
loss
is
progressive,
but we
are
unable
to
consider
these more
distant
potential
costs
for
the
subgroup without
confirmed
hearing
loss
(
n
= 4)
due
to
lack
of
data.
3
Medical
costs were calculated using a multi-hospital
cost accounting database.
Though
we’d
prefer
to
use
Medicaid/CHIP
cost
reimbursement
figures,
limited
access
to
such
data
required we
use
hospital
cost
as
a
proxy.
4
Data
from
the Census Bureau
indicates
that 23% of Utah
children
(all
ages)
are
on public
insurance, but national data broken down by age
indicates
that
insurance
rates
for
the
youngest
children
tend
to
be much
higher,
45.2%
[14]
2013
Annual
Social
and
Economic
Supplement
Current
Population
Survey,
City,
2013.
Utah
Department of Health data
indicates
that 37.5% of
children born
in 2013 were born
on public
insurance
[15]
Bergevin A,
Personal Communication with Kobi Young
at
the
Utah
Department
of
Health,
City,
2014.
All
of
these
data
points
represent
historical
coverage
rates
and do not
account
for
changes
caused
by
the Affordable
Care
Act
(ACA)
and
potential
Medicaid
expansion
in
the
state.
Even
without
Medicaid
expansion,
the
state
estimates
that
using
current
eligibility
guidelines,
63.5–80%
of
children
are
eligible
for
CHIP
or
Medicaid;
if
larger
numbers
of
individuals start
taking advantage of
their eligibility
from
the ACA,
then state public
insurance
for
infants
could
reach
higher
rates
than
ever
before.
5
Use
of
antiviral medications
to
treat
hearing
loss
in
otherwise
asymptomatic
CMV patients
is
still experimental. We assume a majority of patients will
choose
to
undergo
antivirals
because
preliminary
data
shows
that
to
be
the
case
in Utah.
A.
Bergevin
et
al.
/
International
Journal
of
Pediatric Otorhinolaryngology
79
(2015)
2090–2093
116