Map of life expectancy at birth from Global Education Project.

Thursday, April 07, 2016

Finishing up on the QALY thing . . .

Fortunately, just as I was beginning to lose the thread, Thomas A. Farley comes along in NEJM to make my point for me. A small explainer is needed -- in order to compare the benefits of various health-related interventions, we need a "common currency." It's not enough just to look at life extension. On the one hand, some interventions don't necessarily extend life at all, but they still have value because they relieve pain and disability. Others may extend life, but with very poor quality.

So Quality Adjusted Life Years are a commonly used measure of benefit. They're controversial and I actually buy some of the criticisms. Here's the Wikipedia article. There are a few different ways to calculate QALYs, but basically, they're based on survey data -- asking people how much life expectancy they would trade to be free of a disease state, for example. One major problem with this is that once you actually have the disease state, if it isn't horrific, you probably still want to go on living just as much. The QALY concept can be viewed as devaluing the lives of the sick and disabled. However, that's only when viewed retrospectively -- given the survey, most people can still answer the question.

Regardless, whether you go along with the QALY concept or not, as Farley explains, and as I have already said, resources are limited so we implicitly place a value on human life (or health) all the time. But our ethical intuitions lead us to bizarre conclusions. Farley gives the example of a woman with incurable cancer, whose life can be extended for a few months at a cost of $80,000. Most people insist on giving her the treatment, and by law, Medicare is not even permitted to consider cost in approving treatments. But . . .

We could extend far more lives for far longer for far less money, very easily, but we decide it costs too much. To take an obvious example, anti-tobacco campaigns in the mass media, according to Farley, cost less than $300 per QALY gained, which is a tiny fraction of the cost of cancer treatment; but they occur only sporadically. (Come to think of it, I can't remember seeing one for years.)

Why is cost the main consideration when it comes to prevention, and benefit the only consideration when it comes to treatment? Note that this is essentially the conservative or Republican approach to population health, with a weird exception -- provide every possible treatment, no matter what it costs, to everybody who is lucky enough to have insurance. (Which means that other people -- taxpayers or ratepayers -- are in fact paying for it.) Of course, people who can't afford insurance can just die in the street. But I thought human life was infinitely precious? I guess Sarah Palin's is, anyway. On the other hand, spending money to improve air and water quality, improve children's nutrition, provide better quality housing, or whatever the preventive measure may be that extends life and health, is Big Government, Nanny State, and deprives us of our Freedom.

This obviously makes no sense.

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