— Lawmakers Say QALY Limits Access to Care. Click here to read the article.
— Statement Supporting the Protecting Health Care for All Patients Act. Click here to view PIPC's statement of support.
— Stakeholder Views on Components of "Patient-Centered Value” in Health and Health Care. Click here to view the report.
— PCORI 2023 and Beyond: Opportunities for Funding and Involvement in Patient-Centered Research. Click here to view the webinar.
— PCORI Request for Information to Enhance Workforce Development Now Open. See details below.
— No Value Without Equity: Action Opportunities Emerging from the IVI Health Equity Initiative. Click here to view the brief.
— Emerging Threats in States for Use of Discriminatory Metrics. See details below.
— What Happens in Countries Using QALYs and Cost-Based Thresholds? See details below.
— ICER's QALY-Based Study Topics. See details below.
— Upcoming Events and Webinars. See details below.
— AHRQ Effective Program Updates. See details below.
1. Lawmakers Say QALY Limits Access to Care. An article in POLITICO notes that Republicans and some Democrats on the Energy and Commerce Health Subcommittee found potential common ground Wednesday: Legislation that would end the use of a metric they say discriminates against people with disabilities. “Families need hope, not a government that has power over life and death,” Chair McMorris Rodgers said. The subcommittee’s ranking member, Rep. Anna Eshoo (D-CA), also said she supports ending use of the metric because it doesn’t give equal weight to the lives of people with disabilities. Click here to read the article.
2. Statement Supporting the Protecting Health Care for All Patients Act. PIPC applauds the Protecting Health Care for All Patients Act and encourages its swift passage into law. PIPC Chairman Tony Coelho stated, “As with the Americans with Disabilities Act, legislation barring QALYs in all federal programs can pass if Members of Congress on both sides of the aisle are determined to work together to get it done. Even in a divided Congress, there are issues such as ending disability discrimination in health care that everyone can agree on. I am grateful that Chair McMorris-Rodgers introduced the bill and is prioritizing its passage.” Click here to view PIPC's statement of support.
3. Stakeholder Views on Components of "Patient-Centered Value” in Health and Health Care. PCORI has recently released draft report on potential components of patient-centered value in health and health care. The report, Stakeholder Views on Components of "Patient-Centered Value” in Health and Health Care, summarizes the result of a multi-step process by PCORI to gather views of patients, families, caregivers, and the broader healthcare community on the potential components, attributes, and measurement of patient-centered value and related data collection. Comments on the report can be submitted through March 3, 2023. Click here to view the report.
4. PCORI 2023 and Beyond: Opportunities for Funding and Involvement in Patient-Centered Research. A PCORI webinar with Executive Director Nakela Cook outlined PCORI's agenda for the year ahead. The discussion also outlined initiatives and opportunities for funding, including research, dissemination and implementation, and engagement awards, as well as ways to get involved with PCORI through advisory panels, the Ambassador program, merit reviews, and more. Click here to view the webinar.
5. PCORI Request for Information to Enhance Workforce Development Now Open. For this RFI, PCORI is seeking input on the opportunities, gaps, and challenges in the current PCOR workforce landscape, and input on additional programmatic initiatives, investments, and/or partnerships that would accelerate the development of the PCOR workforce and facilitate the conduct of PCOR in alignment with PCORI’s National Priorities for Health, Research Agenda, and Strategic Plan. Comments should be submitted to [email protected]. by March 17, 2023. Click here to view the RFI.
6. No Value Without Equity: Action Opportunities Emerging from the IVI Health Equity Initiative. The Innovation and Value Initiative (IVI), as part of the Health Equity Initiative (HEI), recently conducted a series of key informant interviews with stakeholders that reinforced these themes and identified early learning opportunities applicable to the field of health economics research and health technology assessment. Their research brief summarizes this work to date and reinforces their belief that without explicit attention to equity, health technology assessment risks reinforcing or exacerbating disparities in the U.S. healthcare system. Click here to view the brief.
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. We encourage you to keep track of all state-based threats using this new website tracking state activities. Key issues are highlighted below.
- 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.
Minnesota
The Minnesota state legislature has introduced a bill to create a Prescription Drug Affordability Board, HF 17. It was heard by the Commerce Finance and Policy Committee on January 23, 2023. It does not include a bar on using QALYs or other metrics that discriminate. Also, the bill specifically references Canadian prices as a consideration for establishing the upper payment limit for drugs, prices which are explicitly based on QALYs.
Massachusetts
An Act Advancing Health Care Research and Decision-Making Centered on Patients and People with disabilities, SD. 2117 and HD. 3356 has been introduced in both the House and Senate. This bill includes important patient protections including a ban on the discriminatory Quality-Adjusted Life Year (QALY).
North Dakota
The North Dakota Senate considered SB 2031 in committee creating a "Prescription drug reference rate pilot program” calling for reference to select Canadian provinces or the Canadian government to establish a ceiling price - in effect relying on the quality-adjusted life year (QALY) to determine coverage and reimbursement within the state’s Medicaid program similar to other countries that restrict access to care that is not considered “cost effective.” There was significant testimony in opposition to the bill.
California
On August 31, 2022, California Attorney General Rob Bonta sent letters to hospital CEOs across the state requesting information about how healthcare facilities and other providers are identifying and addressing racial and ethnic disparities in commercial decision-making tools. The request for information is the first step in a DOJ inquiry into whether commercial healthcare algorithms – types of software used by healthcare providers to make decisions that affect access to healthcare for California patients – have discriminatory impacts based on race and ethnicity. Click here to view the Attorney General’s letter. Click here to view a response from advocates urging the Attorney General to include QALYs and similar metrics in his investigation. In March 2022, ICER received a grant from the California Health Care Foundation to develop annual unsupported price increase reports as well as a policymaker guide for using its research to determine “fair” access and pricing to drugs. Advocates are concerned of the implications of this grant given ICER’s reliance on QALYs. Click here to view the letter to CHCF from advocates.
Nevada
On September 22, 2022, the Nevada Patient Protection Committee received a presentation highlighting efforts have been undertaken in other states with the goal of lower drug prices including establishing a Prescription Drug Affordability Board, relying on ICER’s unsupported price increase report, and referencing the prices of Canadian drugs, risking reliance on metrics that discriminate with potential implications for access to care, similar to the experience of patients and people with disabilities in Canada. The Committee meeting did not include participation from patients and people with disabilities, and the Committee did not discuss the discriminatory implications of the QALY.
Oregon
On October 6, 2022, the Oregon Health Evidence Review Commission (HERC) Value based Benefits Subcommittee discussed a proposed plan for using QALYs, including proposals to redact the word QALY from the HERC’s deliberations without barring the use of the metric in making decisions. The meeting followed CMS approval of Oregon’s waiver application, which does not bar the use of QALYs in the interim. Click here to read comments submitted by PIPC along with 62 other groups asking CMS to reject the waiver. Click here to view the CMS-approved waiver. At the HERC meeting, the Oregon Health Authority expressed its intent to continue using a prioritized list, shifting it from use under a waiver to use as part of the State Plan Amendment after the waiver expires in 2027. The HERC decided to accept comments on options to either adjust their use of QALYs or to cease mentioning QALYs at meetings and redact their mention from published articles, despite vehement opposition from advocates based on the implications for discrimination and health equity, as well as the potential lack of transparency related to their use to make decisions if simply redacted from studies considered by the HERC. Click here to view the letter from almost 50 advocacy groups asking the HERC to stop using QALYs, to support Oregon’s health equity goals and to lead in developing alternative coverage strategies that do not discriminate. Click here to view testimony from PIPC Chairman Coelho to the Oregon HERC expressing his support for the Americans with Disabilities Act and the implications of QALYs for violating existing federal civil and disability rights laws. Click here to view the options that continue to be under consideration by the HERC to continue using QALYs. Click here to view all of the comments shared with PIPC.
International News: What Happens in Countries Using QALYs and Cost-Based Thresholds?
Other countries are often referenced as examples of how the use of QALYs or similar cost-based thresholds impact access to care.
- Australia: A family is pushing for life-changing medication to be made available for their four-year old daughter who has cystic fibrosis.
- Canada: When it comes to access to treatment for patients with rare disorders, the Canadian Health Policy Institute argues that Canadians are 40 years behind the U.S.
- New Zealand: SMA patients are being forced to leave the country to get access to life-saving treatments due to the lack of access to a vital treatment.
ICER's QALY-Based Study Topics
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.
- Amyotrophic Lateral Sclerosis (ALS): Final Evidence Report and Meeting Summary available. Evidence Presentation available. Draft Evidence Report available. Public comments closed. Model Analysis Plan available. Research Protocol available. Revised Scoping Document available.
- Sickle Cell Disease: Research Protocol available. 02/27/2023: Model Analysis Plan. Revised Scoping Document available. Draft Scoping Document available. Public Comments closed.
- Non-Alcoholic Steatohepatitis: Draft Evidence Report available. Public comments open until 3/16/2022. Model Analysis Plan available. Research Protocol available. Revised Scoping Document available. Draft Scoping Document available. Public comments closed.
- Menopause: Vasomotor Symptoms: Final Evidence Report and Meeting Summary available. Evidence Report and Presentation available. Draft Evidence Report available. Model Analysis Plan available.
- Alzheimer's Disease: Draft Evidence Report available. Public comments open until 2/2/2023. 3/1/2023: Evidence Report. Model Analysis Plan available. Research Protocol available. Revised Scoping Document available.
- Beta Thalassemia: Final Evidence Report and Meeting Summary available. Evidence Presentation available. Draft Evidence Report available. Public comments closed. Model Analysis Plan available. Research Protocol available. Revised Scoping Document available.
- COVID-19: Final Evidence Report and Meeting Summary available. Evidence Presentation and Report available. Draft Evidence Report Available. Public comments closed. Model Analysis Plan available. Draft Scoping Document and Research Protocol available.
- Obesity Management: Final Evidence Report and Meeting Summary available. Evidence Presentation available. Draft Evidence Report available. Model Analysis Plan available. Research Protocol available.
- Multiple Sclerosis: CIS, RRMS, and SPMS: Evidence Presentation available. 2/17/2023: Final Evidence Report and Meeting Summary. Evidence Report available. Draft Evidence Report available. Model Analysis Plan available. Research Protocol available. Revised Scoping Document available. Draft Scoping Document available.
- Gene Therapies for Hemophilia A and B: Final Evidence Report and Meeting Summary available. Evidence Presentation available. Evidence Report available. Draft Evidence Report available. Public comments closed. Model Analysis Plan available. Revised Scoping Document available. Draft Scoping Document available.
- Type 2 Diabetes: Final Evidence Report and Meeting Summary available. Evidence Presentation available. Evidence Report available. Draft Scoping Document and Research Protocol available.
- Hypertrophic Cardiomyopathy: Final Evidence Report and Meeting Summary available. Evidence Report Available. Evidence Presentation available.
- Asthma: Final Evidence Report and Meeting Summary available. Evidence Presentation available. Evidence Report available.
Upcoming Events and Webinars
PCORI Board of Governors Meeting
February 14, 2023
Click here to view.
PCORI Advisory Panels -- Applicant Town Hall
February 14, 2023
Click here to view.
PCORnet Studies Applicant Workshop
May 18, 2023
Click here to view
Medical Journal Articles
A Patient-Centered Comparative Effectiveness Research Study of Culturally Appropriate Options for Diabetes Self-Management. Click here to view.
Payer–patient Engagement Framework to Strengthen Ethical Formulary Decision-making in Rare Disease Arena in the USA. Click here to view.
The Impact on Cost-Effectiveness of Accounting for Generic Drug Pricing: Four Case Studies. Click here to view.
A Perspective on Life-Cycle Health Technology Assessment and Real-World Evidence for Precision Oncology in Canada. Click here to view.
Identifying And Exploring Bias in Public Opinion on Scarce Resource Allocation During The COVID-19 Pandemic. Click here to view.
Machine Learning Applied to Patient-Reported Outcomes to Classify Physician-Derived Measures of Rheumatoid Arthritis Disease Activity. Click here to view.
Patient-Centered Pain Care Using Artificial Intelligence and Mobile Health Tools: A Randomized Comparative Effectiveness Trial. Click here to view.
AHRQ Effective Program Updates
Systematic Review: Partian Breast Irradiation for Breast Cancer. Click here to view.
Systematic Review: Use of Telehealth During the COVID-19 Era. Click here to view.
Research Report: Analysis of Requirements for Coverage with Evidence Development (CED) - Topic Refinement. Click here to view.
Technical Brief: Infection Prevention and Control for the Emergency Medical Services and 911 Workforce. Click here to view.
Systematic Review: Management of Infantile Epilepsies. Click here to view.
Systematic Review: Pharmacologic and Nonpharmacologic Treatments for Posttraumatic Stress Disorder. Click here to view.
Systematic Review: Living Systematic Review on Cannabis and Other Plant-Based Treatments for Chronic Pain. Click here to view.