The QALY is Discriminatory

  • by: Robert Goldberg |
  • 06/23/2020

Real Clear Health

Should Our Health Care System Place a Dollar Value on Lives?
By Charles Camosy & Robert Goldberg
June 22, 2020
The COVID-19 pandemic is proving to be a catalyst for a long-overdue discussion in this country about our health care system and whether some lives should be considered more valuable than others. Are some Americans comparably more expendable and less deserving of measures to save or extend their lives?

Earlier this month, Oklahoma provided the nation what we believe is the only just answer: it banned state agencies from deciding who gets treatments based upon a bureaucratic measure of the value of life called a QALY.

Those who haven’t heard of the acronym QALY should get to know it. It stands for Quality Adjusted Life Year and it is a scoreboard that divides our population into health care winners and losers. QALYs are used to prioritize the use of ventilators and hospital beds for the younger and healthier and able-bodied—while denying care to those with lesser physical or mental capabilities.

And it’s used by policymakers to decide who should get new medicines, including those to treat COVID-19. Increasingly, unelected and unaccountable organizations such as the Institute of Clinical and Economic Review (ICER) are being used by policymakers, government health programs and insurers to ration care. ICER’s use of QALYs in making these recommendations is inherently discriminatory and may even violate the federal civil rights of the elderly and disabled to be treated equally in medical facilities which get federal funds.

As if this huge moral and legal problem with using QALYs wasn’t bad enough, there are other problems. For instance, ICER arbitrarily decided that an additional year of healthy life is worth $50,000. This dollar value was established in 1982 to determine how much kidney dialysis would be needed to keep someone with kidney failure alive. This while the EPA assumes an additional year of life is worth up to $3 million.

Further, the QALY benchmark inherently assumes people with disabilities or older or harder to treat are worth less. People with disability or your underlying illness – be it heart disease or diabetes – your QALY score is lower and the value assessment scorekeepers will likely recommend that insurance coverage simply isn’t warranted. And if you are someone with a rare disorder such as ALS or Parkinson’s your worth is lower still.

Further, ICER claims that no matter how valuable a drug is — even if it cures — we should only spend $1 billion a year on it. Their rationale: since new drugs might be needed to be taken for a long time, the people who use them might live longer if they stay on a medicine, then total health care spending will increase. By comparison, as ICER states, medicines that help people who are healthy are more ‘cost-effective.’

Recently ICER rushed out a price recommendation of $4300 for remdesivir, the new drug that treatments people hospitalized with COVID-19. In making that assessment, ICER ignores circumstances that any ethical person would consider.

Remdesivir, at the very least, reduces the amount of time people spend in the hospital with COVID-19 by four days. $38,755, depending on the cost-sharing provisions of their health plan.  That doesn’t include post- COVID-19 cost or the fact that for every additional day in the ICU, readmission and death rates post hospitalization climb. It also doesn’t include that fact that if Remdesivir had been available before the pandemic, we wouldn’t have had the overflow of ICU patients.  Cutting length of stay by four days would have increased hospital bed turnover, freeing up enough ICU and non-critical care capacity.  And that would have meant not shutting down the economy.

And yet the talk is about rationing drugs like Remdesivir. Incredibly, those that would be harmed most by rationing are precisely the people who suffered most because of the policies designed to free up hospitalization. Rationing would target the frail veterans who were herded into nursing homes where they died and those whose care was already delayed despite the very people at greatest risk of COVID-19.

The pandemic exposed the fact ICER’s justification for rationing has little to do with scarcity and lot to do with protecting a set of relationships and institutions that support a culture who discards the most vulnerable.

This throwaway culture has a primary value: maintaining a consumerist lifestyle. Proponents of this kind of rationing claim that health care spending – particularly money spent on those with the greatest unmet need – will not be as economically efficient. In an example of brutal honesty, then, groups like ICER want to obtain good outcomes by excluding care and other resources for those who need it the most.  

The QALY systematically deprives those who have been marginalized the same right to health and those of us who are more privileged take for granted. It makes a mockery of our nation’s founding claim that all of us are created equal.

As we move into – and beyond – this new phase of the pandemic, we should follow Oklahoma’s lead. We should reject a discriminatory culture reinforced by QALY-based policies. And we should support a counterculture in which the marginalized are encountered, embraced, cared for, and protected in the fullness of human equality before the law.

Charles C. Camosy is Associate Professor of Theological and Social Ethics at Fordham University and author of “Resisting Throwaway Culture: How a Consistent Life Ethic Can Unite a Fractured People, New City Press”, 2019.  Robert Goldberg is Vice President, Center for Medicine in the Public Interest and co-cost of the Patients Rising podcast.

Center for Medicine in the Public Interest is a nonprofit, non-partisan organization promoting innovative solutions that advance medical progress, reduce health disparities, extend life and make health care more affordable, preventive and patient-centered. CMPI also provides the public, policymakers and the media a reliable source of independent scientific analysis on issues ranging from personalized medicine, food and drug safety, health care reform and comparative effectiveness.

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