Tuft’s Joshua Cohen Talks about Quality-Adjusted Life-Years

The controversy over the use of quality-adjusted life-years (QALYs) tools as part of health assessment has become a little more complicated. These tools assess a drug’s impact on health outcomes and quality of life and have become a standard part of health economic research. For example, the Institute for Clinical and Economic Review uses both QALY and equal value of life years gained (evLYG) assessments to determine how a new drug improves patients’ lives. The evLYG metric measures any gains in length of life regardless of the quality of life gained.

Disability rights advocates and other groups have been critical of QALYs because they say the measurement discriminates against people with disabilities and other illnesses.

House Republicans passed legislation in February 2024 that would prohibit federal agencies, Medicare Advantage plans and Medicaid managed care organizations from using QALYs in coverage and payment determinations. The legislation, sponsored by Energy and Commerce Committee Chair Rep. Cathy McMorris Rodgers (R-Wash.), would prohibit the metric and other similar measures. The Affordable Care Act banned QALYs and similar measures in Medicare “as a threshold to determine coverage.” And the IRA doesn’t allow for QALYs to be used in Medicare drug price negotiation.

Joshua T. Cohen, Ph.D.

But Joshua T. Cohen, Ph.D., said the effort to restrict the use of QALYs is misguided. Cohen is the deputy director and chief science officer of the Center for the Evaluation of Value and Risk in Health and a research professor of medicine at the Institute for Clinical Research and Health Policy Studies at Tufts Medical Center, Tufts University School of Medicine.

Q: Explain the controversy with the QALYs metric.

Cohen: It stems from this idea that QALYs discriminates against people whose quality of life, because of whatever health condition they have, is diminished. In a sense that could be true if it is used to suggest that we should prioritize the person whose life isn’t diminished.

But that is the wrong way to look at it. The QALYs tool is not being used to say that the life of a person with an adverse health condition is worth less. It’s really being used to say that if we could address that health condition, there would be a greater potential to add value compared with someone who doesn’t have that condition. It’s a measure of the value that comes from restoring a person to health. If you have a more severe condition, then the added quality-adjusted life years are worth more to you than if you start out in good health.

Q: Is evLYG an alternative tool to measure the value of a therapy?

Cohen: evLYG is a measure that attempts to address the discrimination against people who have adverse health conditions. But the downside is that any improvement in quality of life is completely invisible in the evLYG measure. It puts no value on, say, living a pain-free life for someone with arthritis.