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How not to bend the cost curve

Posted Oct 18 2010 8:12pm

Among the many compromises in the Patient Protection and Accountable Care Act (PPACA) is the prohibition against using quality-adjusted life years (QALYs) for coverage, reimbursement or incentive programs. The idea, presumably, is to repel the suggestion that PPACA enables “rationing” or death panels.

Yet, as comparative effectiveness researchers Peter Neumann and Milton Weinstein argue in the New England Journal of Medicine ( Legislating Against Use of Cost-Effectiveness Information ):

At a time when health care costs loom as the greatest challenge facing our country’s well-being, legislating against the use of the standard metric in the field of cost-effectiveness analysis is regrettable.

I agree with them on this.

The authors put forward multiple arguments in favor of QALYs:

  • They provide a way to make apples-to-apples comparisons across disease categories and to ascertain the effectiveness of both treatment and prevention
  • QALYs are used worldwide, including by US government agencies –because they are useful
  • Medical societies use QALYs in support of clinical guidelines
  • QALYs aren’t perfect, but they are an important input for decision making

They also take issue with some of the attacks on QALYs:

  • Although detractors argue that using QALYs would discriminate against the old and disabled (that’s the death panel paranoia) it’s not really a fair point. First, those with greater impairment typically fare well in a QALY regime, since they have more to gain from effective interventions than healthy people. Also, it’s very reasonable to evaluate medical spending against the objective of a longer, healthier life. Do we really want to argue that extending the life of a 100 year old in a coma has the same value as curing a child of leukemia?
  • Those who attack QALYs engage in “magical thinking” that we can avoid tradeoffs and resource constraints

To me the “magical thinking” point best describes what’s going on in this country, with health care and politics in general. It’s time to face up to runaway health care costs, but if we insist on ignoring data and banning the use of valuable measures we’ll never get there.

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