Oklahoma Bans the QALY

June 18, 2020

Oklahoma legislators have taken a stand for seniors and Americans with disabilities or chronic conditions.

Under the “Non-discrimination in Health Care Coverage Act,” now signed into law by Governor Kevin Stitt, state agencies cannot determine access to medications or health care services using discriminatory measures.  

In particular, the law calls out a metric known as the QALY, or quality-adjusted life year.  The controversial metric is often used to assign a value to medications.  Health plans may then limit coverage for treatments deemed low value, making it difficult for patients to access them.

Discrimination & Health Care Value

The QALY, and metrics like it, is problematic for certain patient populations.  

  • Patients with disabilities and chronic disease. The metric gauges how close to a year of “perfect health” a medication can get a patient. People living with disabilities or chronic diseases, however, could improve significantly but still not achieve what’s considered “perfect health” for the broader population.  
  • Older patients.  The QALY factors in how long a medication may extend a patient’s life.  Older patients have fewer years ahead of them than younger patients do, so the metric inherently undervalues medications for older patients. 

Oklahoma’s law will stop any agency that might “discount the value of a life because of an individual’s disability, including age or chronic illness.”  

Patient Advocates’ Response

In passing the law, Oklahoma addresses increasing concerns from patient advocates about using the QALY to determine what a medication is worth – and whether a patient can access it.  In a letter to Governor Stitt, The Headache & Migraine Policy Forum noted that the QALY leads to “insufficient consideration of the patient definition of value.”  Because the QALY is a generic metric, it cannot reflect the individual values of actual patients.

Several other patient advocacy organizations also weighed in in support of the bill.

Health Technology Assessment & Patient Access

The QALY has come under fire in recent years due to its frequent use by the Institute for Clinical and Economic Review.  The controversial health economics organization uses the QALY to assess the value of breakthrough medications, typically before they are available to patients.  

Health plans can use the organization’s determinations to justify high out-of-pocket costs for patients or barriers to access such as step therapy and prior authorization.  Implementing these measures, known as utilization management, will in Oklahoma now first require a public comment period.

Oklahoma’s law goes into effect November 1.

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