Lives 75% Worth Living?
posted by Frank Pasquale
The NYT had a fascinating section on the business of health care yesterday. One piece provides a nice introduction to “Quality-Adjusted Life Years” as a measure of efficiency in medical interventions. The basic idea is that we would choose to pay less for an intervention that restores a sick person to less-than-perfect health than for an intervention that restores her to perfect health.
Rationing has been part of U.S. health care policy for some time, angry assertions to the contrary notwithstanding. It’s just that the U.S. does so in a pretty random way, based largely on the insurance status of the ill person involved.
Now policymakers are trying to develop some more rational methods of allocating care. Consider whether you’d allocate funding to treat, say, late-stage diabetes, blindness, or sleep apnea. You may want to intervene to help cure the more serious condition. How can you compare them?
The QALY equation assigns “point values” to different states of health; for example, “if a blind person’s quality of life is ‘worth’ 0.75 points per year, a treatment that would restore him to perfect vision — and raise his quality of life to 1 per year — is worth 0.25 per year of life.” But how do we get at those values?
[E]conomists have developed several tests. The simplest and most elegant is called the standard gamble. People are asked to imagine having the symptoms of a certain disease — the pain, loss of function and shortened life expectancy. . . . Then the people are told that an operation exists that would cure them. But if the operation fails, the patient will die. Under those circumstances, what odds of failure will the sick person tolerate? The higher the odds, the worse the disease. For example, a survey of people with severe diabetes, including blindness, found that they would accept the operation even if there were only a 42 percent chance they would survive, according to a registry compiled by Dr. Neumann’s program at Tufts. . . . [A]pnea patients would accept an operation only if their chances of dying were no higher than about 10 percent.
Of course, imagining a situation is far different than being in it. Echoing some recent work by Jeremy Blumenthal on affective forecasting, the director of the National Institute on Aging says “People are terrible at doing this. . . . There are data that show that people overestimate the impact of spinal cord injuries compared to people who’ve actually had them.” Moreover, QALY’s raise a hornet’s nest of disability and age discrimination issues ably canvassed in Hall, Bobinski, and Orentlicher’s Law of Healthcare Finance and Regulation.
A final challenge to QALY’s is calculating the value of the “years of life” they serve as a coefficient for. The article suggests $100,000 to $300,000 per year, which is consistent with studies like this. I worry that certain biases, like the ones that affected the 9/11 Victims’ Compensation Fund, could sneak in here.
Nevertheless, as Dana Goldman (the director of health care economics at RAND) says, “The reality is we have to make these comparisons.” I just hope that, whatever health care reform plans are adopted, more are made explicitly in the light of day by public boards like Massachusetts’s Connector, rather than behind the scenes at private insurers prone to call their rationing mechanisms a “trade secret.”
Photo Credit: Flickr/Green.thumbs (Uncle Sam on Dialysis).
June 12, 2007 at 3:39 pm
Posted in: Health Law
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Responses (2)
Dave - June 12, 2007 at 5:54 pm
I agree that we need to make tradeoffs, but the concern I have is that they will be structured in a way the systematically entrenches existing inequalities.
Afflictions that disproportionally effect the poor will probably be given less weight than those that afflict the wealthy, because the poor’s “quality” of life will be seen as lower.
That said, it’s hard to imagine how our current healthcare system could possibly be any worse in that regard, so I suppose any change is somewhat welcome.
Daniel Goldberg - June 12, 2007 at 11:36 pm
The fact that we have to find some way of rationing does not mean that QALYs are the best way of making these painful decisions. I would be much more comfortable with public assessments of rationing if they were not overtly based on a medical model of disability.
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