Patients and people with disabilities face major threats as private insurers and government programs look to cut costs using quality-adjusted-life-years (QALY) and other assessments that discriminate against patients, people with disabilities, and seniors. Recently, new threats have emerged, including: (1) a pharmacy benefit manager's new plan to limit access to prescription drugs using a rigid cost-per-QALY threshold, similar to that used by the United Kingdom's National Health Service; (2) the use of cost-per-QALY thresholds by New York's Medicaid program; and (3) a new Medicare proposal that would set reimbursement for physicial-administrated medicines based off decisions made in countries that use QALYs and cost-effectiveness thresholds to set national coverage. Join us in opposing discriminatory denials of care across our health insurance system. Patients and people with disabilities deserve to have our lives valued, because nobody should be considered too expensive to get the care they need.
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“It’s devastating to not even be able to try a drug that could work for you… I understand a line has to be drawn but it feels unfair that other people make decisions about your life and how much it's worth.”
- Patient with breast cancer in the U.K.
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“It’s incredibly cruel to use the cost-effectiveness line and it makes me shake with rage…It’s like being in a dystopian society – it has been approved in Scotland and the US and Europe but England is just lagging so far behind… It’s an abomination of human rights that the drug isn’t available. It feels like discrimination against his disability.”
- Parent of child with SMA in the U.K.
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"There's no way I can't try this drug. It's the last thing that might save my life… It's crazy that I live in Canada, but now I'm looking at having to sell my house for coverage of my medication."
- Patient with breast cancer in Canada
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"'If they do approve it in September, she could be too far gone and then we’d be told it’s not worth the NHS’s resources."
- Parent of child with Batten’s disease in the U.K.
What Happens in Countries Using QALYs and Cost-Based Thresholds to Determine CoverageOther countries are often referenced as examples of how the use of QALYs or similar cost-based thresholds impact access to care:
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Case Studies
United Kingdom
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Ireland
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Canada
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Australia
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Germany
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CVS: Value Our HealthIn August, CVS announced that they would offer new insurance plans that exclude drugs if they exceed a subjective “cost-effectiveness” threshold.
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PIPC Response to CEVR Article on ICER's New 'evLYG'In response to a recent blog post entitled “Will ICER’s Response to Attacks on the QALY Quiet the Critics?” PIPC Chairman Tony Coelho replies: Absolutely not.
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