How not to bend the cost curve

Among the many compromises in the Patient Protection and Accountable Care Act (PPACA) is the prohibition against using quality-adjusted life years (QALYs) for coverage, reimbursement or incentive programs. The idea, presumably, is to repel the suggestion that PPACA enables “rationing” or death panels.

Yet, as comparative effectiveness researchers Peter Neumann and Milton Weinstein argue in the New England Journal of Medicine (Legislating Against Use of Cost-Effectiveness Information):

At a time when health care costs loom as the greatest challenge facing our country’s well-being, legislating against the use of the standard metric in the field of cost-effectiveness analysis is regrettable.

I agree with them on this.

The authors put forward multiple arguments in favor of QALYs:

  • They provide a way to make apples-to-apples comparisons across disease categories and to ascertain the effectiveness of both treatment and prevention
  • QALYs are used worldwide, including by US government agencies –because they are useful
  • Medical societies use QALYs in support of clinical guidelines
  • QALYs aren’t perfect, but they are an important input for decision making

They also take issue with some of the attacks on QALYs:

  • Although detractors argue that using QALYs would discriminate against the old and disabled (that’s the death panel paranoia) it’s not really a fair point. First, those with greater impairment typically fare well in a QALY regime, since they have more to gain from effective interventions than healthy people. Also, it’s very reasonable to evaluate medical spending against the objective of a longer, healthier life. Do we really want to argue that extending the life of a 100 year old in a coma has the same value as curing a child of leukemia?
  • Those who attack QALYs engage in “magical thinking” that we can avoid tradeoffs and resource constraints

To me the “magical thinking” point best describes what’s going on in this country, with health care and politics in general. It’s time to face up to runaway health care costs, but if we insist on ignoring data and banning the use of valuable measures we’ll never get there.

October 18, 2010

One thought on “How not to bend the cost curve”

  1. According to The Dartmouth Institute For Health Policy & Clinical Practice, “nine out of ten deaths are associated with just nine chronic illnesses,” and “32% of total Medicare spending is in their last two years of life.” The study goes further to explain that the care provided, was not in line with the wishes of the patients, “do not have improved survival nor better quality of life,” and vary by region.

    http://www.dartmouthatlas.org/data/topic/topic.aspx?cat=18
    “More than 80% of patients say that they wish to avoid hospitalization and intensive care during the terminal phase of illness, but those wishes are often overridden by other factors. If more intense intervention does not improve life expectancy, and if most patients prefer less care when more intensive care is likely to be futile, the fundamental question is whether the quality of care in regions with fewer resources and more conservative practice styles is better than in regions where more aggressive treatment is the norm”

    If this information is true and “Bending The Curve” is our goal, why don’t we deal directly with this issue? Frankly, I believe providers often take advantage of those at the end of life for monetary reasons, which is disgusting. We need a plan that respects the wishes of terminal patients, with dignity, without expensive and invasive practices on a nationwide basis.

    I don’t have to be a PHD to see the underlying reason for runaway healthcare spending. As long as we have a third party payer system, where the patient has little or no “skin in the game,” we are going to continue with this struggle. When patients take ownership of their healthcare expenses, we will see true “Bending The Curve.” HSA’s and HRA’s were a good step in the direction of patient ownership, but didn’t go far enough. There is a new business model where employers contribute healthcare funds to employee-owned accounts. Employees can use their accumulated account funds to purchase an insurance policy of their choice, and pay for other qualified medical expenses with Visa “smart” cards, all with pretax dollars. If this business model spreads, we could see a real Bending of the Curve. Here’s a article regarding this model.

    http://www.washingtonstatewire.com/home/3714-how_about_a_401_k_program_for_health_insurance.htm

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