First Encounters of the QALY Kind

The first time I encountered cost-effectiveness research was during a stint at the Harvard School of Public Health in the early ’90s (the injection of T.H. Chan into the school’s name came much later). I was a journalism fellow there and then worked as a writer and editor. The details have slid outside my recall, but I do remember Professor Milton Weinstein’s long, elaborate cost-effectiveness calculations—and uneasiness. Some of it was the complexity; my feeble, non-STEM mind couldn’t grasp it all. Some of it was the modeling; the figuring seemed to be based on way too many assumptions.

Weinstein’s work most likely dealt with QALYs. But my (presumably faulty) first memory of QALYs is wedded to Christopher J. L. Murray when he was at Harvard and his first Global Burden of Disease study. Murray’s study—which continues to be regularly updated with fresh data—is a systematic effort to objectively measure health status around the world. He measures in DALYs (disability-adjusted life years) not QALYs, but they are closely related.

So here we are, decades later, and the finer points of cost effectiveness are still arcane and difficult. But it’s far from being just an academic exercise.

As Lola Butcher reports in her story on the Institute for Clinical and Economic Review on page 30, insurers and drugmakers are tracking ICER’s cost-effectiveness work closely. Indeed, ICER has become one of those known acronyms in the world of pharma and managed care. In the fights about drug prices and value, ICER’s judgments are taking on added weight and sending a message. Just ask Janssen. ICER published a report in early May on Spravato (esketamine), Janssen’s nasal spray for treatment-resistant depression. At $295 per 28-mg dose and, by ICER’s calculations, $198,000 per QALY, ICER said the spray is “well above the commonly cited cost-effectiveness thresholds.” Translation: At that price, it’s not worth it.

Cost effectiveness. Sigh. And QALYs—I remember you guys.

Thanks, ICER. You are bringing back memories.