” QALY have been used for years by governments around the world to help determine what treatments citizens can obtain under public health care. In America’s free-market health care system, however, QALY calculations have largely been avoided. As McNary and others like her are finding out, that’s starting to change.
In the United States, however, QALY-based assessments have not gained traction until recently.
In fact, QALY-based cost-effectiveness reviews are so controversial that the federal government has repeatedly quashed their use. In 1992, the Department of Health and Human Services rejected Oregon’s attempt to use QALY-based cost-effectiveness assessments to determine what services its Medicaid program would cover. In 2010, as part of the Patient Protection and Affordable Care Act, Congress prohibited the use of QALYs by the Medicare program. It also banned the federal Patient-Centered Outcomes Research Institute from using QALY thresholds in its assessments of comparative treatments.
As you know this Administration is doing everything it can to modify Medicaid and Medicare and cancel out the ACA.
Traditionally, however, private insurers have generally not used QALYs explicitly in their decisions about what tests and treatments they will pay for, according to a recent report by the National Council on Disability. Instead, when major U.S. insurers decide to limit access to a given medication, they usually cite insufficient data to justify its use in a given situation.
Indeed, until recently, U.S. insurers did not have a source for QALY-based cost-effectiveness reports. That began to change in 2014, when the Institute for Clinical and Economic Review, a nonprofit research organization based in Boston, turned its attention to high-cost drugs.
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my point, QALY may come into our lives and soon. Therapies could be threatened. it begs the question, does my $6000 dose really cost Bristol Squibb $5500 to make or $35 to make and the rest is just markup? It will matter in a QALY world.
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