Some Recent Citations on COST, QALY, PREVENTION and QUALITY; Incl. SSA 1182 on QALYs

 I was seeing too many citations about Medicare cost vs quality to keep in my head, so I'm quickly memorializing some of them here. I include at bottom SSA 1182 (from ACA) on CMS, QALY, and discrimination against the elderly or disabled with inherent low QALYs.

Super impressed by paper by Zhu et al. 2023 on how endorsed stroke measures are wildly all over the map regarding QALY performance.

https://www.acpjournals.org/doi/abs/10.7326/M22-3186

In the same vein, Do CMS Quality Measures Reflect Cost Effectiveness Evidence, by Van Dover 2021.

https://pubmed.ncbi.nlm.nih.gov/34711358/

Section 1182 of SSA, from ACA, forbids Medicare to use QALY in coverage and incentive (quality) programs, although it does say, "not in a  way that is prejudicial to older or ill people".  I quote in full down at bottom of this blog.

https://www.ssa.gov/OP_Home/ssact/title11/1182.htm

N ew bill would extend the ban on QALY to Medicare, e.g. article at Georgetown

https://ccf.georgetown.edu/2023/03/06/house-bill-prohibiting-use-of-qalys-is-overbroad-could-undermine-state-negotiation-of-medicaid-supplemental-rebates/

Other news on same:

https://bio.news/federal-policy/legislation-potentially-banning-qalys-due-to-discrimination-is-under-review/

Peter Neumann March 2023 writes in STAT on why QALYs are vital tool, not discriminatory

https://www.statnews.com/2023/03/22/the-much-maligned-quality-adjusted-life-year-is-a-vital-tool-for-health-care-policy/

Lacdawalla have used the occassion to emphasize GRACE and other adjusted measures instead of QALY.  Multiple articles avaialble.

https://healthpolicy.usc.edu/article/alternatives-to-the-qaly-for-comparative-effectiveness-research/

See a 2021 open access review on QALY and policy decisions at JAMA Ethics

[1] https://journalofethics.ama-assn.org/sites/journalofethics.ama-assn.org/files/2021-07/pfor2-peer-2108_0.pdf  

Older, but a detailed 59 page law review article, through 2005, by Fox:

 https://scholarcommons.sc.edu/cgi/viewcontent.cgi?article=2098&context=law_facpub

SSA 1182

 

LIMITATIONS 

IMITATIONS ON CERTAIN USES OF COMPARATIVE CLINICAL EFFECTIVENESS RESEARCH

Sec. 1182. [42 U.S.C. 1320e-1] (a) The Secretary may only use evidence and findings from research conducted under section 1181 to make a determination regarding coverage under title XVIII if such use is through an iterative and transparent process which includes public comment and considers the effect on subpopulations.

(b) Nothing in section 1181 shall be construed as—

(1) superceding or modifying the coverage of items or services under title XVIII that the Secretary determines are reasonable and necessary under section 1862(l)(1); or

(2) authorizing the Secretary to deny coverage of items or services under such title solely on the basis of comparative clinical effectiveness research.

(c)(1) The Secretary shall not use evidence or findings from comparative clinical effectiveness research conducted under section 1181 in determining coverage, reimbursement, or incentive programs under title XVIII in a manner that treats extending the life of an elderly, disabled, or terminally ill individual as of lower value than extending the life of an individual who is younger, nondisabled, or not terminally ill.

(2) Paragraph (1) shall not be construed as preventing the Secretary from using evidence or findings from such comparative clinical effectiveness research in determining coverage, reimbursement, or incentive programs under title XVIII based upon a comparison of the difference in the effectiveness of alternative treatments in extending an individual’s life due to the individual’s age, disability, or terminal illness.

(d)(1) The Secretary shall not use evidence or findings from comparative clinical effectiveness research conducted under section 1181 in determining coverage, reimbursement, or incentive programs under title XVIII in a manner that precludes, or with the intent to discourage, an individual from choosing a health care treatment based on how the individual values the tradeoff between extending the length of their life and the risk of disability.

(2)(A) Paragraph (1) shall not be construed to—

(i) limit the application of differential copayments under title XVIII based on factors such as cost or type of service; or

(ii) prevent the Secretary from using evidence or findings from such comparative clinical effectiveness research in determining coverage, reimbursement, or incentive programs under such title based upon a comparison of the difference in the effectiveness of alternative health care treatments in extending an individual’s life due to that individual’s age, disability, or terminal illness.

(3) Nothing in the provisions of, or amendments made by the Patient Protection and Affordable Care Act, shall be construed to limit comparative clinical effectiveness research or any other research, evaluation, or dissemination of information concerning the likelihood that a health care treatment will result in disability.

(e) The Patient-Centered Outcomes Research Institute established under section 1181(b)(1) shall not develop or employ a dollars-per-quality adjusted life year (or similar measure that discounts the value of a life because of an individual’s disability) as a threshold to establish what type of health care is cost effective or recommended. The Secretary shall not utilize such an adjusted life year (or such a similar measure) as a threshold to determine coverage, reimbursement, or incentive programs under title XVIII.