One concern raised by critics of a government-run, single-payer healthcare system like Medicare for All is that the government will start rationing health care to keep costs down.
But some healthcare industry players are already trying to ration health care by using the QALY system.
Quality-adjusted life years, or QALYs, were “originally developed as a measure of health effectiveness for cost-effectiveness analysis, a method intended to aid decision-makers charged with allocating scarce resources across competing health-care programs,” according to the medical journal Value in Health. They are used by firms like the U.K.’s National Institute for Health and Care Excellence (NICE) and the U.S.’s Institute for Clinical and Economic Review (ICER) to guide drug price decision-making.
Sometimes NICE and ICER use QALY analysis to pressure drug companies to lower their prices. However, they also are used to prevent drugs from going to market or discourage health insurance companies from covering costly drugs, which can prevent patients from receiving life-saving or life-improving treatments.
Here’s how QALYs work: if a person suffering from depression or multiple sclerosis has a QALY value of 0.5, that means they have 50 percent of the value of one year of life of a healthy person. The underlying principle is to mathematically quantify the quality of life for people with certain health conditions.
If, say, the price for an antidepressant is too high relative to how much it would improve the quality of life of a depressed individual — who already has a shorter life expectancy than an average healthy person — then a firm like ICER will recommend that antidepressant not go to market.
Earlier this year, ICER released a report recommending the “miracle drug” for depression, esketamine, not go to market for these reasons.
Mental health advocates, disability advocates, and other patient advocates say the QALY method dehumanizes patients and inaccurately measures how much one year of life is worth.
William Smith, Ph.D. and visiting life sciences fellow at the Pioneer Institute, described the U.K.’s bad experience with QALYs in an op-ed: “A cancer drug that provides ‘only’ eight additional months of life won’t achieve a maximum QALY score,” he wrote. “Yet to someone with a cancer treated by that drug who may be facing certain death, a drug that delivers an extra eight months of life should get the highest possible rating. The use of QALYs in the United Kingdom’s National Health Service so limited Britons’ access to new cancer therapies that Parliament ignored the QALY methodology entirely and created a ‘Cancer Drugs Fund’ that would pay for new cancer drugs regardless of their QALY ratings.”
By default, any health system that uses QALYs discriminates against those with disabilities or chronic health conditions.
“QALYs are a very crude measure, and typically fail to capture what matters most to patients,” Andrew Sperling, Director of Legislative Advocacy at the National Alliance on Mental Illness (NAMI), told InsideSources. “And in some European countries, using these crude assessments to argue well, maybe another couple years of life aren’t that important after all, and then putting a dollar on that. And in the case of disability, there’s a lower dollar value placed on your extra year of life than for other people.”
Sperling told InsideSources said the U.S. Medicare system already has other discriminatory problems, so he’s worried that 2020 presidential candidates’ Medicare for All plans will discriminate against anyone with a unique or chronic health condition.
“Irrespective of QALYs, NAMI has strong reservations about any single-payer system that uses as its base the most discriminatory method, which is the Medicare Fee-for-service (FFS),” he said.
2020 presidential hopeful Sen. Bernie Sanders (I-Vt.) and Rep. Pramila Jayapal (D-Wash.) both introduced Medicare for All bills to the Senate and House respectively, but neither address the use of QALYs.
The 2010 Affordable Care Act banned Medicare from using “cost-effectiveness research,” but the National Disability Council thinks the language is too vague and recently said Congress should explicitly ban the use of QALYs across all federal programs (state Medicaid programs are allowed to use QALYs).
But the more pressing problem is that American drug companies and health insurance companies are already listening to ICER and allowing the QALY method to dictate how and whether or not patients get the drugs they need.
“In an effort to lower their healthcare costs, public and private health insurance providers have utilized [QALYs] to determine the cost-effectiveness of medications and treatment,” the National Disability Council wrote in a letter to President Donald Trump this week. “The lives of people with disabilities are equally valuable to those without disabilities, and healthcare decisions based on devaluing the lives of people with disabilities are discriminatory.”