Is it Finally Time for QALY Policies in US Healthcare?

!ping HEALTH-POLICY

QALY, quality-adjusted life year is a measure of a person's health that combines the length and quality of their life. It is used in economic evaluations to assess the value of medical interventions.

QALYs are calculated by:

• Estimate the number of years a patient has left after a treatment or intervention
• Weight each year with a quality-of-life score on a scale from 0 to 1

One QALY is equal to one year of life in perfect health.

Currently NICE uses a threshold of £30,000 per Quality Adjusted Life Year to gauge whether the health benefits offered by a new drug are greater than the health likely to be lost because the additional resources required

In the 1980s Medical care at the end of life consumes 10% to 12% of the total health care budget and 27% of the Medicare budget.

According to the National Institue of Health as of 2012, Nearly 30% of all Medicare spending occurs during the last six months of a patient’s life.

How and where to draw such lines are central questions as the country seeks to contain soaring health spending amid a rush of technological advances and as more patients join cost-conscious, prepaid health plans like H.M.O.'s, a goal of President Clinton's proposals for revamping the nation's health care system.

But one case made headlines and made everyone take a step back

In 1991, Nelene Fox, a 38-year-old mother of three, was diagnosed with breast cancer. She underwent bilateral mastectomies and chemotherapy but nonetheless developed bony metastases. Her physicians said her only chance for survival was high-dose chemotherapy and autologous bone marrow transplantation. A costly new kind of therapy that involves the harvest and retransplant of her own bone marrow–high-wire medicine occupying what one of her physicians calls “the twilight zone between promising and unproven treatments."

• Doctors say 5% or more die from the treatment itself

Her Health Maintenance Organization (HMO) refused to cover the procedure (around $140,000 – $220,000) on the basis that it was experimental.

Her husband launched a successful fundraising effort raising the $220,000, and Mrs Fox received the procedure, but died eight months later. Her brother, an attorney, sued the HMO for the delay in her therapy, and won $89 million in damages.

• The Jury Award sent nervous tremors through the health insurance industry, which is struggling to define limits on the coverage of therapies that are experimental or have only a slight chance of success.

Similar lawsuits played out across the country with similar awards against insurance firms, including PacifiCare, Maxicare and Blue Shield of California–all of which have generally denied coverage for breast cancer-related bone marrow treatments on the ground that it is experimental.

“The bone marrow transplant issue gets at part of the crux of the health-care crisis,” said Dr. James Gajewski, a member of the UCLA Medical Center bone marrow transplant team. “What do you do with patients with a terminal disease who may have a chance of cure” with therapy that’s inconclusive? he asked. “How do you pay for it?”

However, as clinical trial results rolled in, the story began to unravel.

• An early positive report from researchers in South Africa proved to be fraudulent.
• National Institutes of Health (NIH)-sponsored trials, long delayed, finally showed the new treatment to be no more effective than standard chemotherapy,
  • but more toxic.

By The time the negative results became available, 42,000 women in the US had been treated at a cost of $3.4 billion.

• Physicians and hospitals were generally enthusiastic, optimistic, and sincere in supporting the new regimen for late-stage breast cancer, and the new approach was a financial windfall for physicians and hospitals

Other “advances” that increased costs without improving quality are easy to find.

• Rofecoxib (Vioxx) was recalled after its association with myocardial infarction became apparent, but only after, by one estimate, 140,000 avoidable heart attacks.3 Most who took it would have done as well with ibuprofen because they had a low risk of gastrointestinal bleeding.
  • Nonetheless, rofecoxib resulted in expenditures of nearly $2.5 billion per year while it was on the market.
• Arthroscopic debridement and lavage for knee osteoarthritis has been a popular treatment. However, randomized trials suggest it is no more effective than sham surgery or rehabilitation.
  • Nonetheless, costs of the procedure were estimated at $3 billion per year.

Welcome to La Crosse, Wisconsin– a Midwestern everytown USA that has managed to transcend Sarah Palin’s death panel rhetoric not only to become the “cheapest place to die in America.” But, more importantly, they have transformed the entire "tenor of care" for end-of-life planning.

• La Crosse, Wisconsin spends less on health care for patients at the end of life than any other place in the country, according to the Dartmouth Health Atlas.

"It turns out that if you allow patients to choose and direct their care, then often they choose a course that is much less expensive," says Jeff Thompson, CEO of Gundersen.

By 1995, 85 percent of people that died in La Crosse County had an advance directive and by 2009 the number had reached 96 percent–more than three times higher than the national average.

Nationally, the average cost for a patient’s last two years of life is $26,000 (in some hospitals average costs run as high as $65,000) the average cost in La Crosse, is just $18,159. More importantly, knowing patients’ wishes ahead of time ensures the best possible care and relieves debilitating emotional and financial stress for families.

https://www.nytimes.com/1993/12/30/us/89-million-awarded-family-who-sued-hmo.html
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3034436/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1282187/#:~:text=According%20to%20one%20estimate%2C%20end,%24%2029%20billion%2C%20respectively2.
https://jamanetwork.com/journals/jama/article-abstract/404260
https://www.forbes.com/sites/offwhitepapers/2014/09/23/how-to-die-in-america-welcome-to-la-crosse/
https://www.npr.org/sections/money/2014/03/05/286126451/living-wills-are-the-talk-of-the-town-in-la-crosse-wis
https://www.dartmouthatlas.org/interactive-apps/end-of-life-care/#county
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https://time.com/archive/6728453/medical-care-the-soul-of-an-hmo/
https://www.latimes.com/archives/la-xpm-1992-11-24-fi-1194-story.html