To gauge the relative value of any health intervention the outcome needs to be measured and compared to some desired result. Cost effectiveness analysis is a tool used to compare the cost of outcomes from various interventions. For instance, preventive medical services are compared to other lifesaving interventions using the outcome life years saved. This allows public health advocates to decide how to allocate scare resources. A common preventive medical service is mammograms. The value of mammograms varies depending on the frequency and the age of women it is used on. Annual mammograms in women 55 to 65 years of age saves a year of life at a meager $22,000 per year. That’s considered very cost effective as far as preventive medical services go. Colonoscopies are even cheaper, when applied to adults age 50 to 64 years old, costing only about $12,000 per life year saved. If you were to compare the cost-effectiveness at age 40 the cost per year of life saved would be much higher.
Let’s assume there is a medical intervention that keeps patients alive but sometimes keeps them alive in a coma. In situations like this cost per life year saved may not be so clear cut. A year of hospitalization for a comatose patient would likely amount to several million dollars. Thus, the cost per life year saved would be several million dollars. The logical question is: is a year of life comatose while tethered to a heart/lung machine equal to a year of life when you can run marathons and fully enjoy life? Scientists dealt with this question by creating a standard that’s known as quality-adjusted life years (QALYs). The theory is that a year of life is not always the same. Some life years are better than others.
Believe it or not, this standard is somewhat controversial, at least to some. QALYs are meant to quantify that a year of life while able to run a marathon is better than a year of life tethered to a machine keeping your comatose body alive. Does this also mean that a year of life confined to a wheelchair is worth less than a year of life running a marathon? Not necessarily, but advocates for the disabled oppose the concept on principle. Axios reported on a recent Congressional committee meeting:
A divided House of Representatives on Wednesday endorsed banning quality-adjusted life years from being used as a metric for determining a drug’s value in federal health programs.
Why it matters: QALYs are viewed as a key tool in comparative effectiveness studies, but have been held up as discriminatory against people with disabilities — and are unevenly applied across federal programs.
Keep in mind, when the concept of QALY was first debated it was hailed as a huge advance in cost-effectiveness analysis. But are medical ethicists unable to make allowances for disabilities that affect quality of life versus those that don’t? Managed Healthcare Executive wrote:
Cost-effectiveness groups such as the Institute for Clinical and Economic Review (ICER) and many academics use QALYs as a starting point, often with adjustments and additional factors, folded in, for assessing drugs and other medical interventions and their prices.
When used for the purpose of comparing treatments and drugs, advocates for the disabled worry that the standard will shortchange therapies for those with disabilities or degenerative health conditions. More on the ethical dilemma from Axios:
They are used to calculate how many years a drug could help prolong a person’s life — but factor how a patient feels during those extra years to determine if a medicine is worth the price.
That’s raised sensitive bioethics questions, such as whether it’s worth less to treat a person with a serious developmental disability.
This is where it gets odd in my opinion. Democrats fear the measure is an attempt to weaken public health efforts. The Biden Administration opposes efforts to further ban QALYs, claiming that provisions in the Affordable Care Act and also provisions in the Inflation Reduction Act ban the use of QALYs in Medicare. The measure is a priority of some Republicans, however, fearing it could be used to render therapies and treatments for a person with ALS, or downs syndrome, Parkinson’s, etc. less valuable. What do you think? I think it appears to be much ado about nothing.