Cost-effectiveness thresholds used in the United States vs most favored nations

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Abstract
Objectives: Cost-effectiveness thresholds inform whether health interventions represent good value for money, yet their use varies across countries. This study compares thresholds cited in published cost-effectiveness analyses (CEAs) in the United States with those in countries designated as the Most Favored Nations (MFNs) under the 2025 President's Executive Order on prescription drug pricing. Methods: We analyzed 6876 cost-per-QALY studies published between 1979 and 2023 from the Tufts CEA Registry. We standardized thresholds as multiples of each country's GDP per capita, and used logistic regression to estimate the probability of citing a threshold >1 × GDP per capita, adjusting for region, intervention type, disease area, and study period. Results: Over time, MFN studies shifted toward citing lower thresholds, whereas US thresholds consistently cited thresholds >1 × GDP per capita. After adjusting for other factors, MFN studies were less likely to cite higher thresholds than US studies. Cancer-related CEAs and CEAs of pharmaceutical interventions were more likely to cite higher thresholds. Conclusions: CEAs in the United States and peer high-income nations cite remarkably different thresholds, with MFNs citing lower value benchmarks over time. Policymakers should be cautious about adopting pricing policies that would implicitly subject US pharmaceutical spending to benchmarks developed in different institutional and fiscal contexts.

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