1. PIPC Holds 12th Annual Forum: The Call to Action to Bar Reference to Discriminatory Metrics in U.S. Health Pricing and Coverage Policy. Click here to view the forum.
2. IHP: Disability Agency Urges Congress to Ban QALYs in All Federal Programs. Click here to read the article ($). Click here to view the NCD letter sent to Congress.
3. Patient Advocates Push to Overhaul Oregon Medicaid's 'Prioritized List' for Care. Click here to read the article.
4. PCORI Board of Governors Meeting. Click here to view the meeting transcript.
5. IVI-MDD Value Model Draft Protocol: Public Comment Period is Open! See details below.
6. PIPC and Morning Consult Publish Poll Showing Strong Support for NCD Recommendations to Ban QALYs. Click here to view the poll results.
7. PCORI Seeks Nominations for Advisory Panels. Click here to learn more, submit a nomination, or apply to be on an advisory panel.
8. Effective Treatments for People with Chronic Diseases and Disabilities are Being Denied Based on the Discriminatory Quality-Adjusted Life Year. Click here to read the full article.
9. DREDF Releases Report Responding to a Flawed ICER Analyses, Instead Finds that QALY Violates Disability Nondiscrimination Law. Click here to view the report.
10. Upcoming opportunity within the Center for Evidence and Practice Improvement at AHRQ, see details below.
11. International News: What Happens in Countries Using QALYs and Cost-Based Thresholds to Determine Coverage? See below for more.
12. Emerging Threats in States for Use of Discriminatory Metrics, see details below.
13. ICER's QALY-Based Study Topics: Alzheimer's Disease, Beta Thalassemia, Chemotherapy-Induced Neutropenia, COVID-19, Type 2 Diabetes, Hypertrophic Cardiomyopathy, Asthma, Unsupported Price Increase, Fair Access: Coverage Policies. Click here to provide patient input.
14. Upcoming Events and Webinars, see details below.
15. Medical Journal Articles, see details below.
16. AHRQ Effective Program Updates, see details below.
The 12th Annual PIPC Forum on The Call to Action to Bar Reference to Discriminatory Metrics in U.S. Health Pricing and Coverage Policy, focused on the recommendation of the National Council on Disability (NCD) for an unambiguous ban on the quality adjusted life year (QALY) within the text of the Build Back Better Act (H.R. 5367), as well as the increasing reference to comparative and cost effectiveness assessments in determining reimbursement, coverage, and programs at the state and federal level. Click here to view the forum.
The Chairman of the National Council on Disability, Andrés Gallegos, stated, “In our most recent advice to Congress we advise that Congress extend those prohibitions [prohibitions against the use of the QALY in the ACA] throughout federal programs. The Build Back Better Act is a tremendous opportunity to do so and to memorialize the protections with an unambiguous ban on the use of the QALY. We remain hopeful that our advice will be heeded as we all await the final text of that bill.”
2. IHP: Disability Agency Urges Congress to Ban QALYs In All Federal Programs
Inside Health Policy highlighted statements made by the Chairman of the National Council on Disability (NCD) at the annual PIPC Forum. The article stated, "After getting the Senate Finance Committee to ban Medicare from using a common metric for appraising drug prices, the government agency National Council on Disability is asking Congress to use the Build Back Better bill to prohibit the use of the quality-adjusted life years metric in all government programs.” The article stated that the NCD sent a letter to Congress encouraging the inclusion of a QALY ban within the bill that applies to all Medicare price negotiation and that is extended to all government programs. The article highlighted that the "U.S. government does not have a uniform policy on QALYs. Some federal agencies are banned from using measurement tools like QALYs, but state Medicaid programs use them.” Chairman Gallegos was quoted as stating, “In our most recent advice to Congress we advise that Congress extend those prohibitions [against the use of the QALY in the ACA] throughout federal programs.” Chairman Gallegos also stated, “The Build Back Better Act is a tremendous opportunity to do so and to memorialize the protections with an unambiguous ban on the use of the QALY.” Click here to view the article (subscription required). Click here to view the NCD letter sent to Congress.
3. Patient Advocates Push to Overhaul Oregon Medicaid's 'Prioritized List' for Care
The Portland Business Journal published an article on how patient advocates are pushing to overhaul Oregon Medicaid's drug list to ensure people with disabilities are not denied care. The article stated, "The U.S. Department of Health and Human Services in 1992 denied Oregon’s use of the “quality-adjusted life year” metric as discriminatory.” The article also highlighted that, "Disability rights advocates are pushing Oregon’s Medicaid program to change how it decides which treatments to cover in order to ensure that people with disabilities are not discriminated against and denied services. Disability Rights Oregon’s request comes as the state prepares its application to the federal government to renew its Medicaid waiver for another five years. The application, to be submitted to the Centers for Medicare and Medicaid Services in February, includes changes to advance health equity, while maintaining the coordinated care model Oregon created nearly a decade ago. But Disability Rights Oregon would like the program to use a different methodology for deciding what rises 'above the line' on Oregon’s Prioritized List of health services and is fully covered, and what falls below. 'There are medically necessary treatments not being covered by Oregon’s Medicaid program that a state not operating under a waiver is required to provide,' said Meghan Moyer, the organization’s public policy director." Click here to read the full article. Click here to view and sign the letter being circulated by Disability Rights Oregon.
4. PCORI Board of Governors Meeting
On December 2, 2021, PCORI held a meeting of its Board of Governors. At its meeting, PCORI's Board of Governors approved two slates of research funding awards totaling $49.5 million to support nine new comparative clinical effectiveness research (CER) studies aimed at improving care for adults and children across a range of health conditions.
The Board also approved the development and release in 2022 of two Targeted PCORI Funding Announcements. One will fund studies comparing the effectiveness of ways to prevent or treat alcohol use among youth ages 12 through 17, while the other will fund research assessing interventions to prevent, detect early or treat delirium in older adults. Click here to view the meeting transcript.
5. IVI-MDD Value Model Draft Protocol: Public Comment Period is Open!
As part of its Open-Source Value Project, the Innovation and Value Initiative (IVI) is holding a public comment period on the draft model protocol on major depressive disorder from December 14, 2021 – January 18, 2022. IVI held a webinar on Wednesday, December 15th where they outlined the major components of the model protocol and answered initial questions. The model protocol is a technical document that outlines the primary inputs we plan to use in the MDD economic model. The purpose of the public comment period is to obtain feedback in the following three main areas before they finalize the model protocol: (1) Data gaps in key model inputs and potential data sources and partners to address such gaps; (2) Prioritization of data sources and technical approaches, when multiple valid approaches exist; and (3) Potential use cases, particularly how the MDD model can help inform decisions in your organizations. Please submit comments either on letterhead via email at firstname.lastname@example.org or through their online survey form, which allows you to submit comments related to the key questions or to provide general feedback. No anonymous comments will be accepted, and all comments will be published on the website.
6. PIPC and Morning Consult Publish Poll Showing Strong Support for NCD Recommendations to Ban QALYs
Morning Consult ran a poll on behalf of Partnership to Improve Patient Care focusing on the use of cost-effectiveness assessments to determine the value of coverage and treatment costs. The survey found that Americans want patients and their doctors in charge of health care decision making and are opposed to the use of cost assessments such as Quality-Adjusted Life Year (QALY).
PIPC Chairman Tony Coelho published an opinion piece in Morning Consult about the poll, stating, "Ten years after the Partnership to Improve Patient Care (PIPC) released its first public opinion survey, our latest poll released today underscores how vitally important it is for lawmakers to maintain and strengthen safeguards for patients and people with disabilities in all health care policies.” Chairman Coelho was heartened to see the National Council on Disability — an independent federal agency that advises Congress and the administration on disability policy — recently come out with targeted recommendations to strengthen BBBA by including meaningful protections against government use of discriminatory cost-effectiveness thresholds based on the quality-adjusted life year (QALY). He emphasized that this recommendation represents an important step in protecting patients and patients with disabilities. Despite the long history in the United States acknowledging that metrics like QALYs discriminate in violation of disability and civil rights laws, their use is rising —not falling. He concluded that it is time to finally end the ambiguity and prohibit QALYs altogether.
7. PCORI Seeks Nominations for Advisory Panels.
PCORI is currently seeking nominations for appointments to its advisory panels. The advisory panels must include patients or patient advocates. PCORI's staff, board, and methodology committee take advisory panels' recommendations into account when making decisions and determinations. PIPC encourages patients and patient advocates to submit nominations to serve on PCORI's advisory panels, including on the Advisory Panel on Clinical Effectiveness and Decision Science, Advisory Panel on Patient Engagement, and Advisory Panel on Rare Disease. Nominations are open through March 31, 2022. Click here to learn more, submit a nomination, or apply to be on an advisory panel.
8. Effective Treatments for People with Chronic Diseases and Disabilities are Being Denied Based on the Discriminatory Quality-Adjusted Life Year
Jenn McNary, patient advocate and mother of two children with Duchenne Muscular Dystrophy published an opinion piece in the Boston Globe supporting the passage of a bill before the Massachusetts Legislature, An Act Advancing Health Care Research and Decision-Making Centered on Patients and People with Disabilities, which would codify patient protections, including a ban on the use of the Quality-Adjusted Life Year. Ms. McNary shares her real-life experience of having ICER’s QALY-based assessment cited as a reason her son could not access a treatment that had previously been effective for him and cautions about Massachusetts’ continued partnership with ICER. Click here to read the full article.
9. DREDF Releases Report Responding to a Flawed ICER Analyses, Instead Finds that QALY Violates Disability Nondiscrimination Law
The Disability Rights Education and Defense Fund ("DREDF") responded directly to a report commissioned for the Institute for Clinical and Economic Review (“ICER”), an organization specializing in clinical cost-effectiveness analyses relying on the QALY, in which its hired legal consultants posit that the use of QALY as a measure of the cost-effectiveness of specific drugs and therapies “poses absolutely no risk of discrimination against any patient group.” DREDF strongly disagrees with this conclusion. In its response, DREDF challenges the factual and legal assumptions of ICER's report and explains how the use of the QALY, even in tandem with alternative measures such as the Equal Value of Life Years Gained (“evLYG”), violates disability nondiscrimination law.
DREDF will join Familia Unida to celebrate National Disabilities Awareness Month and share information about its new report and the ongoing work of the disability community against disability discrimination in healthcare. Click here to view the DREDF report. Click here to view the one-pager. Click here to find summaries in both English and Spanish.
10. Upcoming Opportunity Within the Center for Evidence and Practice Improvement at AHRQ
AHRQ will soon be hiring a Senior Staff Service Fellow in CEPI’s Office of the Director to support activities funded by the Patient-Centered Outcomes Research Trust Fund (PCOR TF) under the National Center for Excellence in Primary Care Research (NCEPCR). The Senior Staff Service Fellow will support AHRQ’s mandated roles under the PCOR TF in evidence dissemination and implementation in primary care as well as of training and capacity building for comparative effectiveness research in primary care settings.
The Senior Staff Service Fellow designs, executes and evaluates projects funded by the PCOR TF to increase the uptake of evidence in primary care including by using new models of primary/ambulatory care delivery, advancing health equity and engaging learning health systems. AHRQ is looking for a team player to lead a multidisciplinary team to design, that leads national initiatives to disseminate and implement PCOR findings related to transforming primary/ambulatory care delivery to make care more equitable and patient-centered including a focus on people living with multiple chronic conditions and other at risk populations.
This Senior Staff Service Fellow will also advise other members of CEPI and AHRQ on dissemination and implementation activities related to the PCOR TF; supports and aligns ongoing primary care projects across all divisions within the Center as well as across AHRQ. Serves as a recognized expert within the areas of primary care, primary care research and implementation science.
11. International News: What Happens in Countries Using QALYs and Cost-Based Thresholds to Determine Coverage?
Other countries are often referenced as examples of how the use of QALYs or similar cost-based thresholds impact access to care.
- Canada: Patient advocates are calling on the government to push forward new regulations to enact price controls on life saving drugs.
- United Kingdom: A promise to ensure that people with severe asthma and smokers can get the drugs they need has been broken by NHS, and health charities are criticizing the persistent lack of access.
12. Emerging Threats in States for Use of Discriminatory Metrics
Several states are considering policies that would reference entities such as the Institute for Clinical and Economic Review (ICER), which calls the discriminatory quality-adjusted life year (QALY) the “gold standard” for value assessment, and others are considering policies to import QALY-based coverage and reimbursement decisions from other countries that restrict access to care. Yet, federal policymakers have emphasized that the use of discriminatory metrics is subject to civil rights laws such as the Americans with Disabilities Act. We encourage sharing resources for advocates in key states mentioned below to ensure protections against discrimination!
- Click here to learn more about the potential for Prescription Drug Affordability Boards to discriminate by incorporating the use of QALYS.
- Click here to view the Value Our Health state template legislation that would protect people with disabilities and chronic conditions from the use of QALYs and similar metrics developed by third parties such as ICER in decisions related to reimbursement and coverage, as well as ensure their engagement in decision-making.
- Click here to view a one pager about the flaws in ICER’s methodology.
- Click here to view information from experts on the downside of referencing foreign countries.
- Click here to learn about statutory protections against use of QALYs.
Other states to watch: Rhode Island, Minnesota and Washington State are also potential targets for future legislation that could trigger the use of discriminatory QALYs.
Oregon is applying to the Centers for Medicare & Medicaid Services (CMS) for a new five-year Medicaid waiver known as the 1115 Demonstration. The purpose of the waiver is to reform the state’s Medicaid program. Advocates have expressed concern about the state’s ongoing use of quality-adjusted life years (QALYs) in determining the prioritized list of services under Oregon’s existing waiver. Click here to view the timeline for providing input. Click here to view and sign the letter being circulated by Disability Rights Oregon.
Efforts are underway to advance legislation that would create a Prescription Drug Affordability Board in the State of Virginia, triggering concerns about potential discrimination, according to recent news. It is not clear that these efforts will include provisions to bar discrimination and protect patient access to medications, such as achieved by disability advocates in other states such as Oregon where the legislature barred the use of QALYs in similar Board deliberations.
Recently, the Legislative Health and Human Services Committee endorsed legislation for 2022 consideration creating a Prescription Drug Affordability Board that would review the affordability of prescriptions drugs based on a variety of factors including the “the relative financial impacts to health, medical or social services costs as can be quantified and compared to baseline effects of existing therapeutic alternatives” which may pose a risk of consideration of QALYs. While the bill explicitly bars consideration of QALYs in the methodology used by the board to establish an upper payment limit for prescription drugs, the affordability review does not bar use of QALYs and could lead to a discriminatory impact by disproportionately subjecting products for people with disabilities to payment limits. According to the legislative calendar, there is little time to engage as legislation may be pre-filed on January 4, 2022 and the session ends on February 17, 2022. We will provide updates as we learn more.
The Maryland legislature passed legislation earlier this year creating a Prescription Drug Affordability Board. The legislation did not include protections for patients and people with disabilities such as barring the use of discriminatory QALYs. The Board has begun meeting to hear from stakeholders, including hearing a presentation from the Institute for Clinical and Economic Review which relies on QALYs to assess treatment value. Legislation was introduced this year to bar the use of QALYs and implement patient protections that has not advanced in the legislature. On August 3, organizations representing patients and people with disabilities sent a letter urging the Board to avoid policies that would potentially discriminate by relying on discriminatory metrics such as QALYs. Click here to view legislation introduced in Maryland to bar the use of QALYs and implement patient protections - it has not advanced in the legislature.
The Governor of Colorado has signed into law SB 21-175, which creates a prescription drug affordability review board. SB 21-75 did include an amendment that prohibits the use of QALYs in the section of the bill that determines an upper payment limit. In some states these types of boards and commissions have referenced value assessments based on QALYs from the Institute for Clinical and Economic Review (ICER). In Massachusetts, the Health Policy Commission went so far as to contract with ICER. In order to mitigate this, it is important that the Board has representation from patients and people with disabilities. The Governor's office is accepting applications for both the Colorado Prescription Drug Affordability Review Board and the Colorado Prescription Drug Affordability Advisory Council. It is essential that the Board and Advisory Committee include representation from patients and people with disabilities to ensure that that the Board’s deliberations do not include consideration of QALYs and other metrics that may discriminate or lead to restricted access for people with disabilities and chronic conditions or older adults.
The Massachusetts House and Senate have each taken the positive step of introducing An Act Advancing Health Care Research and Decision-Making Centered on Patients and People with Disabilities, H.201 and S.753. This bill would enshrine essential patient protections including a ban on the use of the QALY, a requirement for research to meet patient-centeredness criteria, and robust engagement of the patient and disability communities in health care decision making. H. 201 was heard before the Joint Committee on Health Care Financing on November 9. It is important the Committee hear about the discriminatory implications of QALYs from the patient and disability communities. Details on submitting testimony may be found here.
13. ICER's QALY-Based Study Topics: Alzheimer's Disease, Beta Thalassemia, Chemotherapy-Induced Neutropenia, COVID-19, Type 2 Diabetes, Hypertrophic Cardiomyopathy, Asthma, Unsupported Price Increase, Fair Access: Coverage Policies
The Institute for Clinical Economic Review (ICER) conducts cost effectiveness studies for insurers using the cost-per-QALY methodology. ICER provides guidance on its website for patients and patient advocates to provide direct input related to their experiences with the disease. Click here to provide patient input. Click here to view the topics and deadlines.
- Alzheimer's Disease: Draft Scoping Document available. Public Comments open through 1/19/2022. 2/3/2022: Research Protocol. 3/23/2022: Model Analysis Plan.
- Beta Thalassemia: Revised Scoping Document available. Public Comments closed. 1/7/2022: Research Protocol. 2/28/2022: Model Analysis Plan. 4/13/2022: Draft Evidence Report.
- Chemotherapy-Induced Neutropenia: Model Analysis Plan available. Draft Scoping Document and Research Protocol available. 1/25/2022: Draft Evidence Report.
- COVID-19: Model Analysis Plan available. Draft Scoping Document and Research Protocol available. 2/3/2022: Draft Evidence Report.
- Type 2 Diabetes: Draft Evidence Report available. Public Comments closed. Draft Scoping Document and Research Protocol available. Meeting 1/20/2022: Deliberation and vote on evidence presented in ICER's report on therapies for Type 2 Diabetes.
- Hypertrophic Cardiomyopathy: Final Evidence Report and Meeting Summary available. Evidence Report Available. Evidence Presentation available.
- Unsupported Price Increase: Final Report available.
- Asthma: Final Evidence Report and Meeting Summary available. Evidence Presentation available. Evidence Report available.
- Fair Access: Coverage Policies in 2020: Protocol Available. Final Report available.
14. Upcoming Events and Webinars
Cycle 1 2022 -- Improving Methods for Conducting Patient-Centered Outcomes Research PFA Applicant Town Hall
January 18, 2022
Click here for details.
Cycle 1 2022 -- Prevention, Early Identification, and Treatment of Delirium in Older Adults Targeted PFA Applicant Town Hall
January 24, 2022
Click here for details.
15. Medical Journal Articles
“It’s Time to Represent”: Shifting the Paradigm to Improve the Quality of Inputs into Value Assessment Frameworks, click here to view.
Evaluation of Financial Outcomes Under a Value-Based Payment Program for Community Pharmacies, click here to view.
Limited Role of Patient Input in Specialty Drug Coverage Policies, click here to view.
The Importance of Collaboration in Pursuit of Patient-Centered Value Assessment, click here to view.
Toward Better Data Dashboards for US Drug Value Assessments, click here to view.
Prevalence of Avoidable and Bias-Inflicting Methodological Pitfalls in Real-World Studies of Medication Safety and Effectiveness, click here to view.
Association of Co-Pay Elimination with Medication Adherence and Total Cost, click here to view.
The Utility of Patient Engagement in Drug Research and Development, click here to view.
Patient-Powered Research Networks of the Autoimmune Research Collaborative: Rationale, Capacity, and Future Directions, click here to view.
Enhancing Patient Research Partner Engagement: Research in Psoriatic Arthritis, click here to view.
Patient Voices in Value-Based Cancer Care: Priorities for the Biden Administration, click here to view.
The Dollar or Disease Burden: Caps on Healthcare Spending May Save Money, but at What “Cost” to Patients?, click here to view.
16. AHRQ Effective Program Updates
Systematic Review: Prehabilitation and Rehabilitation for Major Joint Replacement. Click here to view.
Integrated and Comprehensive Pain Management Programs: Effectiveness and Harms. Click here to view.
Systematic Review: Management of High-Need, High-Cost Patients: A “Best Fit” Framework Synthesis, Realist Review, and Systematic Review. Click here to view.
Research Protocol: Partial Breast Irradiation for Breast Cancer. Click here to view.
Systematic Review: Physical Activity and the Health of Wheelchair Users: A Systematic Review in Multiple Sclerosis, Cerebral Palsy, and Spinal Cord Injury. Click here to view.
Research Report: Developing and Piloting a Tool to Create Dot Plots to Summarize Pooled Data for Multiple Outcomes in Systematic Reviews. Click here to view.
Systematic Review: Malnutrition in Hospitalized Adults. Click here to view.
Research Protocol: Nutrition as Prevention for Improved Cancer Outcomes. Click here to view.
Research Protocol: Telehealth During COVID-19. Click here to view.
Research Protocol: Pharmacologic and Nonpharmacologic Treatments for Posttraumatic Stress Disorder: An Update of the PTSD Repository Evidence Base. Click here to view.