Rise of evLYG (Equal Value of Life Years Gained) as a supplementary to QALY (quality-adjusted life year) in the US healthcare system

Evolution of evLYG: an alternative measure of QoL in people with disability

Historically, QUALY and DALY were considered to be a composite endpoint of quality of life in many counties including in the UK. Whereas in the US, the use of QALYs has been opposed by people with disabilities and disability rights advocates for more than 20 years. It was first surfaced, in 2008, in one article wherein bioethicists, patient rights groups, and disability rights advocates raised the voice over the discriminatory nature of QALY. It was much evident that in coming years finding an alternative to QALY, as a method of measuring cost-effectiveness will gain significant momentum. Finally, in December 2018, ICER announced their intent to use the evLYG, a supplementary measure in addition to the QALY. Furthermore, it became talk of the town in 2021 when NCD wrote letter to congress recommending QALY ban in Build Back Better Act to prohibit the use of the QALY by Medicaid and Medicare. This move further motivated ICER to include evLYG along with QALY in many of its HTAs.

What is evLYG and what value it provide over QALY?

evLYG measures quality of life equally for everyone (regardless of age, disability, or illness) during any periods of life extension. In other words, evLYG metric measures the cost of a treatment to extend life by one year, without considering the quality of life during that year. So, it avoids discrimination against any patient group. It helps policymakers and payers to look at the broader picture of the benefit offered by the treatment in individual patient group.

Limitations associated with QALY

QALY inherently undervalue the benefit of treatment in people with disabilities and chronic illnesses. This is because it place a lower value on treatments which extend the lives of people with chronic illnesses and disabilities. As a result of this, policymakers and payers (both public and private) will offer restricted insurance coverage to these patient groups.

Some of the rationale behind this argument is reported below:

• Psychiatric disabilities

QALYs undervalue treatments that affect aspects of quality of life other than what they specifically measure. For example, many people with psychiatric disabilities report significant side effects associated with certain medications, like tardive dyskinesia or weight gain. QALY calculations might not consider these aspects.

• Functionally disabled patients

Similarly, the level of QoL experienced by a person with a disability or patient may shift dramatically based on nonhealth factors, such as the availability of reasonable accommodations or the accessibility of the built environment. Typically, the use of QALY assessments in healthcare contexts do not consider these factors.

• Palliative care

Failure to consider all aspects of quality of life, combined with the weighting of quantity and quality of life simultaneously, may lead QALYs to undervalue treatments that are purely palliative in nature.

QALY/evLYG system is not full-proof solution for systemic inequality for disabled population!

• Coverage is not guaranteed under QALY/evLYG system. Example: Spinraza coverage denial recommendation by ICER due to low coverage threshold under both QALY and evLYG methods.
• QALY/evLYG system continue to rely on health utility weights to measure QoL without considering complexity of preferences and experiences of people with disability
• QALY/evLYG system continue to overlook clinical knowledge that is not reflected in the research literature

#NCD #QALY #QOL #evLYG #UShealthcare #ICER