Cost-Effectiveness, the QALY, and the evLYG - ICER

The quality-adjusted life year (QALY) is the gold standard for measuring how well all different kinds of medical treatments lengthen and/or improve ... OurApproach/Methods&Process/Cost-Effectiveness,theQALY,andtheevLYG Cost-Effectiveness,theQALY,andtheevLYG Cost-Effectiveness,theQALY,andtheevLYG Cliniciansplayavitalroleinhelping individualpatients decidewhattreatmentisbestforthem.Incontrast,cost-effectivenessanalysislooksatevidencefor entirepatientpopulations,comparingthehealthbenefitsandeconomiccostsofdifferenttreatmentoptions.Thegoalofcost-effectivenessanalysisistohelpinformpolicysothattreatmentsthatimprovepatients’livesarerewardedfairly,whileneitherpatientsnorsocietyoverpaysforcarethatdoesn’tofferasignificantbenefittopatients. Whatfollowsisanexplanationofhowcost-effectivenessisappropriatelyusedthroughouttheUShealthsystem.Additionalrelatedmaterials,includingalegalbriefconfirmingthatcost-effectivenessanalysesareconsistentwiththeAmericanswithDisabilitiesAct,canbefoundinthesidebartotheright. TheQALY:RewardingtheCareThatMostImprovesPatients’Lives(InstituteforClinicalandEconomicReview)SpecialReport:BigPharmaWagesStealthWaronDrugPricing(Reuters)ICERAnalysesandPayerUseofCost-effectivenessResultsBasedonQALYandevLYGAreConsistentWithADAProtectionsforIndividualsWithDisabilities(EpsteinBecker&Green)TheQALY:RewardingtheCareThatMostImprovesPatients’Lives(InstituteforClinicalandEconomicReview)WhytheComingDebateOvertheQALYandDisabilityWillBeDifferent(TheJournalofLaw,Medicine&Ethics)ObscureModelPutsaPriceonGoodHealth–andDrivesDownDrugCosts(TheWallStreetJournal)ICERReferenceCaseforEconomicEvaluations(InstituteforClinicalandEconomicReview) TheQALYandtheEVLYG Thequality-adjustedlifeyear(QALY)istheacademicstandardformeasuringhowwellalldifferentkindsofmedicaltreatmentslengthenand/orimprovepatients’lives,andthereforethemetrichasservedasafundamentalcomponentofcost-effectivenessanalysesintheUSandaroundtheworldformorethan30years.Ifevidenceshowsthatatreatmenthelpslengthenlifeorimprovequalityoflife,thesebenefitsarecomprehensivelysummeduptocalculatehowmanyadditionalQALYsthetreatmentprovides,andthisaddedhealthbenefitisthencomparedtotheaddedhealthbenefitofothertreatmentsforthesamepatientpopulation. TocomplementtheuseoftheQALY,ICER’sreportsalsoincludeacalculationoftheEqualValueofLifeYearsGained(evLYG),whichevenlymeasuresanygainsinlengthoflife,regardlessofthetreatment’sabilitytoimprovepatients’qualityoflife.Inotherwords,ifatreatmentaddsayearoflifetoavulnerablepatientpopulation–whethertreatingindividualswithcancer,multiplesclerosis,diabetes,epilepsy,oraseverelifelongdisability–thattreatmentwillreceivethesameevLYGasadifferenttreatmentthataddsayearoflifeforhealthiermembersofthecommunity. Byunderstandingatreatment’scostperevLYG,aswellasitstraditionalcostperQALY,policymakerscantakeabroaderviewofcost-effectivenessandbereassuredthattheyareconsideringinformationthatposesnoriskofdiscriminationagainstanypatientgroup. SafeguardLanguagetoEnsuretheEthicalandAppropriateUseofQALY-BasedAnalysis DuetoconcernsfromsomemembersofthedisabilitycommunitythatpolicymakersmayimplementQALY-basedcost-effectivenessanalysesinamannerthathasthepotentialtobediscriminatory,ICERhasputforthformalanti-discriminationlanguagetoguideitsownwork,andtoensuretheappropriateuseofitsworkbyothers: Inconsideringcost-effectiveness,[thestate]cannotusecost-effectivenessanalysesthatusethecost-per-qualityadjustedlifeyearorsimilarmeasuretoidentifysubpopulationsforwhichatreatmentwouldbelesscost-effectiveduetoseverityofillness,age,orpre-existingdisability. Inaddition,foranyprescriptiondrugthatextendslife,the[state’s]analysisofcost-effectivenessmustnotemployameasureormetricwhichassignsareducedvaluetothelifeextensionprovidedbyatreatmentbasedonapre-existingdisabilityorchronichealthconditionoftheindividualswhomthetreatmentwouldbenefit. LongstandingandAppropriateUseofCost-Effectiveness Cost-effectivenessanalysishasalongtrackrecordinacademicworkdonebyresearchersacrosstheUSandinternationally.Itisthecornerstoneofresearchcomparingthevalueofdifferentdrugsandotherhealthcareinterventions.TheUSgovernmentdoesnotcurrentlynegotiatedrugprices,butcost-effectivenessusingtheQALYisusedbyfederalresearchersattheCDCandNIHtoevaluatequestionssuchaswhethernewpediatricvaccinesshouldberecommended.  Asanonprofit,nonpartisanorganization,ICERproducespubliclyavailablecost-effectivenessreportsondrugstohelpinformpolicymaking.TheStateofNewYorkhasusedthesereportsasaninputintoitsMedicaidprogramofnegotiatingdrugprices,joiningmanyothergroupswhohavebeenusingICERreportsformorethan5years,includingtheVeterans’Administration,HarvardPilgrimHealthCare,BlueCrossBlueShieldofMassachusetts,UnitedHealthcare,Aetna,KaiserPermanente,andExpressScripts.  Conclusion Americansdeservetoknowifatreatmentimprovesorharmspatients’qualityoflife.Tothrowoutcost-effectivenessistorejectpatients’livedexperience–anexperiencethathastaughtusthatqualityoflifeshouldserveastheguidetofairdrugpricingandfairpatientaccess. Weallwantgoodaccesstotreatmentthatcanhelpus.Anditiseasytounderstandtheconcernsofsomedisabilitygroupswhohavehistoricallyhadtofighthardforequalaccesstoservices.Truediscriminationagainstpeoplewithdisabilitiescontinuesinthiscountryandhappenseverydaywhenpeoplecan’taffordoraccessthecaretheyneed.Butafundamentalrealityisthat highpricesfordrugswithoutanyanchoringinhowwellthosedrugsactuallyworkisdrivingupoverallhealthcarecosts,andthosespiralingpricesleaddirectlytoreducedaccessandhigheroutofpocketcostsforallpatients. Especiallyforpeoplewithdisabilitieswhooftenhavemorehealthcareneeds. Cost-effectivenessshouldneverbethesolefactorindecidingfairpricingofhealthcareinterventions. Butrejectingitwouldonlyservetokeeppatientslockedintothestatusquo–abrokensystemwheredrugmakerschargewhateverpricetheylike,insurersrespondwithbarrierstoaccess,andpatientsstruggletoaffordandaccessthecaretheyneed.Thatwouldbeatrueethicaltragedyforournation. Patientsdeservebetter. 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