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Thursday, October 21, 2010


A revealing new article titled, “Legislating against Use of Cost-Effectiveness Information” was published last week in the New England Journal of Medicine. In the piece, the authors, Peter J. Neumann and Milton C. Weinstein, attempt to make the case that the Obama Health Care law is flawed in that it did not go far enough in rationing care.

Why? Because it bans the use of the controversial “Quality Adjusted Life Year” or QALY. For the article see here.

From the pro-life perspective this is practically the only dangerous element that ObamaCare doesn’t contain. This fundamental restructuring of the American health system includes a powerful rationing commission. As a result, basically, doctors, hospitals and other health care providers will be told by Washington just what diagnostic tests and medical care are considered to meet “quality and efficiency” standards—not only for federally-funded programs such as Medicare, but also for health care paid for by private citizens and their nongovernmental health insurance. [See here].

At least for now, ObamaCare does not explicitly include the use of QALY or any such equivalent which is a tool often used to discriminate on the basis of disability, age, and “quality of life.” But there are a slew of proponents saying it ought to be included and Obama chose as a key implementer of ObamaCare a man who is a fan of the British health care system which does employs QALY.

But, as noted above, Neumann and Weinstein lament that the QALY is not included.

What is QALY?
In general, a QALY assumes that a year of life lived in perfect health is worth one QALY, and that a year of life lived in a state of less than perfect health is worth less than one QALY. In a system that faces budget shortfalls, this calculation can be used to set an upper limit on the treatment that will be authorized.

This type of assessment is so dangerous, not only because it is being used to ration care abroad, such as by the National Institute for Health and Clinical Excellence in the United Kingdom, but also because we see many influential American academics and health providers advocating the use of QALY.

For one ominous example, we need look no further than Donald Berwick, who Obama appointed to head the Center for Medicare and Medicaid Services which runs the nation's massive Medicare and Medicaid programs. He gave an interview to Biotechnology Health Care in 2009 in which he praised the British system which famously uses QALY’s.

He told Katherine Adams that The National Institute for Health and Clinical Excellence [NICE] has “developed very good and very disciplined, scientifically grounded, policy-connected models for the evaluation of medical treatments from which we ought to learn.” [See here]

A September 13, 2009, USA Today article titled “Kidney Doctors Question Dialysis Guidelines” describes a commentary published in the Journal of the American Society of Nephrology written by Felix Knauf and Peter Aronson. In the prestigious journal, the pair openly says that dialysis rationing would curb Medicare spending on chronic kidney failure in a big way. They lament that “physicians are often willing to provide dialysis care to patients with greatly diminished quality of life.”

In a featured piece in the July 19, 2009, New York Times Magazine, Princeton bioethicist Peter Singer openly advocated government rationing of health care, using QALYs. He made it clear that society should be more willing to withhold treatment from those who are old and those with disabilities.

And now, another example among many, we see an article October 14 in the prestigious New England Journal of Medicine.

The authors of last week’s NEJM piece write that “QALYs provide a convenient yardstick for measuring and comparing health effects of varied interventions across diverse diseases and conditions.” This “yardstick” would mean practicing discrimination against countless patients.

What Neumann and Weinstein ignore is that the assumptions built into the use of quality-adjusted life years are often inaccurate. As Hayden Bosworth of the Duke University Medical Center documents, “Patients who have not experienced a stroke ... or individuals at risk for future stroke ... respond with low [quality of life] estimates for physical impairments. Yet it is clear that patients who actually experience a high level of impairment as a result of a stroke provide high estimates of their quality of life.”

Predictably, the authors write that ban on the use of QALYs in the Obama health law
“…represents another example of our country's avoidance of unpleasant truths about our resource constraints. Although opportunities undoubtedly exist to eliminate health care waste, the best way to improve health and save money at the same time is often to redirect patient care resources from interventions with a high cost per QALY to those with a lower cost per QALY.”

What unfortunately was lost in the mad push for health care legislation was real dialogue about the fact that Americans can afford the kind of health care we want and deserve.

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