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Opinion | Terry Wilcox

A dangerous plan for rationing essential prescription drugs

The midterms are over and it’s time to get back to discussing issues that impact Americans on a daily basis. Things like health care and, specifically how to reduce costs.

President Trump has made lowering the cost of prescription drugs one of his priorities.

It seems to be a bipartisan cause, and all ideas should be on the table. Except one: rationing care to the sickest and oldest patients.

Yet this dystopian scenario is exactly what a Boston-based organization called the Institute for Clinical and Economic Review is recommending as a way to reduce health care costs.

ICER uses a cost-benefit analyses to determine whether patients should have access to medications their doctors prescribe. These are often life-saving and life-extending drugs. The framework they use is called quality of life-adjusted year (QALY).

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QALY is a complicated economic model that attempts to determine the extent to which a given medical treatment extends and improves lifespans. In other words, it determines whether a patient is worth covering after a certain price threshold.

This past summer, Rhode Island-based CVS Caremark, the biggest pharmacy benefit manager (the intermediary between drug manufacturers and insurers), announced that it would allow its insurer clients to exclude from their plans any drugs priced greater than $100,000 per QALY. The CVS decision allows insurers to forbid access to prescription drugs that cost more than $100,000 per extra year lived in perfect health or per extra few years lived in mediocre health.

The problem with QALY is that it is a crude instrument that attempts to measure the impossible: the value of an extra year of life. Putting an objective monetary value on life — especially lived at different qualities — is a fool’s errand. Patients with chronic diseases, for instance, may agree that their quality of life would be improved if they were healthy, but they wouldn’t agree with the QALY proclamation that their lives therefore have less inherent value.

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Sadly, QALY is gaining traction. The New York state Drug Utilization Review Board recently recommended that Medicaid pay less than one-third of the list price for Orkambi, a breakthrough cystic fibrosis drug that treats the underlying cause of the disease for the first time. The value of this medication “cannot be adequately measured in lung function, life expectancy, or even quality of life . . . but on the meaning of my life,” said cystic fibrosis patient Dr. William Elder. “One pill twice a day has enabled me to answer the call to public service as a resident family physician.”

Adherence to cost/QALY tests disregards the doctor-patient perspective, replacing personal and individual health care decisions with an Excel spreadsheet that doesn’t reflect the fact that different drugs work differently on different patients and populations.

This move by CVS, and similar ones by other private and government payers, threatens vulnerable patients — especially those with chronic or rare diseases — the most, because they depend on their prescription drugs for their lives and livelihoods. It may save money but it’s unethical.

A recent report found that about three-quarters of Medicare Part B patients treated for rheumatoid arthritis, multiple sclerosis, lung cancer or multiple myeloma would face barriers to access if the government program used such cost-benefit frameworks to set coverage. It would also reduce cutting-edge research into breakthrough therapies and potential cures because investors couldn’t be sure they’d be able to recoup their investments.

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Congress passed a law forbidding using QALY as a benchmark for access for Medicare. Lawmakers should follow suit and put it off limits to other private and government payers as well. Then we can get back to evaluating the many other quality proposals to lower prescription drug prices.


Terry Wilcox is the co-founder and executive director of Patients Rising.