In response to a recent blog post entitled “Will ICER’s Response to Attacks on the QALY Quiet the Critics?” (December 18, 2018) we must unfortunately reply: Absolutely not. Regrettably, ICER’s response suggests that for patients, the only options are a) a metric that is widely acknowledged to discriminate against the elderly and people with disabilities, or b) a metric that ignores elements of value that are critically important to patients. Patients need another option, and PIPC is committed to supporting it.

The Partnership to Improve Patient Care (PIPC) has a long history advocating for the perspectives of patients and people with disabilities to be considered in the value assessment of treatment options. It is a step in the right direction for the Institute for Clinical and Economic Review (ICER) to advance a new project to develop and test alternative methods for the evaluation of potentially curative treatments.  As part of this work, we encourage ICER to consider innovative methodologies beyond flawed cost effectiveness methodologies that use a quality-adjusted-life-year (QALY) or similar metric.  This process could be an opportunity to learn from the mistakes of other countries that have embraced the use of a cost-per-QALY metric to determine treatment value with serious implications for access to care by people with disabilities and serious chronic conditions.  

This post originally appeared as an op-ed in the San Jose Mercury News on January 2, 2019. 

The Trump administration proposed an “international pricing index” intended to reduce drug spending under Medicare Part B by replicating the rates negotiated in other countries. It seems like a commonsense solution: Why should America pay more than other countries?The truth, however, is more complicated: lower foreign prices emerge from one-size-fits-all health care systems that drive patients to use certain drugs while refusing others, irrespective of individual needs.

Recently, the Institute for Clinical Economic Review (ICER) announced that their future reports will incorporate more prominently “a calculation of the Equal Value of Life Years Gained (evLYG).”  For over a decade, representatives of patients and people with disabilities have communicated to ICER that QALYs are fundamentally flawed and inherently discriminatory. The QALY was developed as a tool to make one-size-fits-all decisions, not facilitate patient-centered health care.

PIPC Chairman Tony Coelho has penned a new blog in Real Clear Health that criticizes CVS Caremark’s use of the quality-adjusted life year (QALY) metric when deciding treatment coverage. “CVS touted its program as an ‘innovation,’ but it is anything but. Under the new policy, CVS would offer employers policies that exclude drugs from their formularies if they exceed a subjective ‘cost-effectiveness’ threshold. CVS would rely on a deeply flawed value assessment model developed by the Institute for Clinical and Economic Review (ICER) in determining whether treatments fall below a $100,000 ‘cost per quality-adjusted-life-year’ limit. Patient advocates have been down this road before. In the early 1990’s Oregon proposed using a similar ‘cost-effectiveness’ formula in Medicaid, but ultimately backed away from it in part due to concern that it discriminated against people with disabilities and would violate the Americans with Disabilities Act.”

In an op-ed for The Hill, PIPC Chairman Tony Coelho outlined his concerns with MedPAC’s pursuit of cost-effective analysis to make coverage and reimbursement decisions. As he writes, "As policymakers encourage a transition towards value-based health care, I worry that more focus is being given to what is most cost-effective for the “average patient” than creating a system that works for each individual patient. I am not average. You are not average. We are the reason a health-care system exists — our health and well-being, our treatment, our recovery."

In an op-ed published in RealClearHealth, PIPC Chairman Tony Coelho examines the limitations of quality-adjusted-life-years (QALYs) and how this tools for value-assessment may systematically discriminate against patients and individuals with disabilities. As he writes, "Underlying all this is the key question we must ask ourselves when considering any policy related to the payment and delivery of health care: for whom are we creating this policy? Who is the ultimate stakeholder? If the answer is not the people served by health systems -- patients and people with disabilities -- then we have a serious problem."

PIPC Chairman Tony Coelho recently penned a blog for HuffPost, complimenting steps that are being taken that show progress in shifting toward value-based healthcare decisions. “While a tremendous amount of work remains to be done, policymakers took two steps recently that show progress is possible. One was approval by the Senate Finance Committee of the CHRONIC Care Act, a bipartisan bill (yes, they still exist!) whose success is attributable to significant stakeholder engagement and that, if enacted, will help to meet real patient needs.”

​​On April 19, 2017, I provided comments to the Centers for Medicare and Medicaid Innovation (CMMI) on behalf of the Partnership to Improve Patient Care (PIPC) related to some new, recently proposed episode payment models.  I applauded the agency for making a deliberate and conscious effort to solicit authentic patient feedback about their proposed new payment models. Although I’ve been critical in the past, I told them that I appreciated their seizing of this opportunity to forge a new path forward on engaging stakeholders, particularly patients, in the development, implementation and evaluation of alternative payment models.

As PIPC continues to play an active role in building a patient-centered healthcare system, we’ve been intensely focused on ensuring that the transition to a value-based health system is built on the foundation of achieving outcomes that truly matter to patients. That’s why PIPC was encouraged when the Center for Medicare and Medicaid Innovation (CMMI) recently announced two models designed to increase patient engagement in care, as well as increase shared decision-making about care and treatment.  

What's the most important question facing any patient with a life-threatening illness?
​
"Which treatment option is best for me?"

By most accounts, this is a good problem to have; giving patients a range of treatment options, and the ability to make an informed choice about the regimen that most directly aligns with their personal health priorities is fundamental to high-quality, individualized health care. But along with these new methods for treatment come difficult questions. Do I want the more aggressive or conservative therapy? Is my quality of life during treatment more important than returning to work quickly? Which course of action has more tolerable side effects? Can I afford the care I need?