QALYs Under Fire
December 3, 2019
Attacks are mounting on a controversial health economics metric that limits patients’ access to care.
The quality-adjusted life year, or QALY, gauges how much a medicine improves a person’s quality of life and life expectancy. But the metric has serious shortcomings, and patients and health advocacy organizations are increasingly speaking out about the QALY.
Consider the National Coalition on Disabilities. The group recently published a report outlining the QALY’s bias against people with disabilities. The report notes that “QALYs are built on a faulty premise: that life with a disability is inherently worse than life without a disability.”
That’s because QALYs measure how effective a medication is at restoring perfect health. In the real world, “perfect health” is defined differently by people. But as defined through the QALY, perfect health is something that people with disabilities can never achieve.
How does this impact patient access? It means that any treatment that improves the lives of people with chronic illnesses or disabilities will be undervalued because it doesn’t provide patients with “perfect health.”
And the National Coalition on Disabilities is not the only group with concerns. The Alliance for Aging Research has criticized the QALY for discriminating against older adults. The metric measures a medicine’s value in part by how long it extends a patient’s life. With older patients, life expectancy is naturally shorter. That makes the QALY inherently discriminatory against treatments for older adults. As the Alliance for Aging Research explains, use of the QALY means “sick and older patients are more likely to be denied access to medications.”
These concerns and others have led Medicare, Congress and the U.S. Department of Health and Human Services to restrict the use of the QALY. But the metric’s shortcomings haven’t stopped the Institute for Clinical and Economic Review, a controversial Boston-based organization that attempts to calculate innovative drugs’ value. ICER uses drug costs and QALY values to calculate whether a drug is cost effective. The lower the cost, and the higher the QALY score, the more cost effective the drug is – in ICER’s opinion.
And that triggers access challenges. The lower QALY value placed on therapies for people with disabilities or chronic diseases and for older adults increases the likelihood that ICER will not find the drug cost effective. Health plans then use ICER reports to justify excluding drugs from coverage or restricting their accessibility.
Concerned patient advocates makes an important point. The QALY gives a one-size-fits-all measure of value that doesn’t reflect the needs and experiences of real patients. If policymakers want healthy patients and lower long-term costs, they might reconsider the choice before them: timely and patient-centered treatment, or financially fueled rationing that only makes patients sicker.
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