The Imperfect QALY: How It's Used Depends on Where You Enter Value Discussions

What is the value of the quality-adjusted life-years (QALYs) metric, and is it perfect as is, or does it need to be changed? Should it be scrapped altogether? Depending on one’s perspective (payer vs patient advocacy group, for example) the QALY connotes different things. At a session “The Controversial QALY: Is There a Middle Ground in the Debate?” during the ISPOR 2019 annual meeting, panelists discussed the good and the bad about the QALY metric from their various perspectives.

The panel was moderated by Jennifer Bright, MPA, the executive director of Innovation and Value Initiative; she was joined by Lou Garrison, PhD, the assistant director of the Pharmaceutical Outcomes Research and Policy Program at the University of Washington; Eleanor M. Perfetto, PhD, MS, the executive vice president of the National Health Council; and Andrew Lloyd, DPhil, a health economics consultant from the United Kingdom.

"I view it as a pragmatic approximation,” said Garrison, who was co-chair of an ISPOR task force on value assessment frameworks.

Consumers are insulated from the price of pharmaceuticals because of health insurance, he said, so traditional economic theory about pricing does not hold when it comes to this industry, he said. In his view, the QALY is a work-around to try and figure out what value is and what should be rewarded. But as a practice in the US, despite the vast amounts of research, policymakers don’t take it into consideration.

He cited 2 problems—value is not highly correlated with price, and there is a lack of real world evidence after launch.

“The US is a very friendly market, everything gets into the market,” Garrison said, as opposed to other countries that are not as willing to pay for every therapy.

From the patient advocacy perspective, Perfetto said the concern about value frameworks is that the patient voice was not present when these were being created. Without the involvement of patients, wrong endpoints will give the wrong answer, she said.

There is fear of access to therapy being cut off, depending on what a report says about QALY and value, she said. “Frankly, the reports get used and they get cherry picked,” she said.

Payers could “hide behind” such pricing reports, Perfetto said. And with decisions like CVS Health deciding to use reports from the Institute for Clinical and Economic Review in formulary decisions, there is concern that the reports are used as a “blunt instrument.”

For instance, a section of a report that says step therapy should never be used may never be used by a payer, she said.

Bringing a different perspective as a resident of the United Kingdom, Lloyd said he focuses on what a treatment does for a patient’s length of life and quality of life. Value “shouldn’t be about rewarding innovation—it should be about purchasing health.”

“I just want to know how much benefit it’s going to give to patients,” he said, and added that he places much less emphasis on innovation.

Bright asked if the controversy and debate about QALY is one of use or one of method.

“I would say it’s both,” said Perfetto, who questioned the use of outdated data.

Garrison took a slightly more different view, saying that the reports start with a review of clinical data and conduct a literature review that comes before a QALY is ever developed. He also reiterated his view that it is not even used much beyond those involved in research.