A controversial healthcare formula that is frequently used to deny patients care and boost insurance profits could soon be banned in Massachusetts.

Three Massachusetts state representatives, Angelo J. Puppolo, Jr., José F. Tosado and Bud L. Williams, have introduced legislation that would block insurance companies, hospitals, health maintenance organizations, and the state’s Medicaid program, MassHealth, from using  “quality-adjusted life years” in providing care to patients. 

“MassHealth shall not any develop or employ a dollars per-quality adjusted life year, or similar measure that discounts the value of a life because of an individual’s disability, as a threshold to establish what type of health care is cost effective or recommended,” the bill states. “MassHealth shall not utilize such an adjusted life year, or such a similar measure, as a threshold to determine coverage, reimbursement, or incentive programs.”

The legislation, House Bill 1088, is garnering strong support from patient advocates, who say that the QALY insurance formula is frequently used to discriminate against patients with pre-existing conditions, rare diseases and chronic illnesses.

“This is groundbreaking legislation,” says Terry Wilcox, executive director of Patients Rising, a national patient advocacy non-profit organization that helps patients overcome insurance barriers to access. “Quality-adjusted life years are a tool that insurance companies and pharmacy benefit managers use to deny access and boost profits.”  

QALY: Anti-Patient Insurance Formula

Known in the health care sector by the acronym “QALY,” quality-adjusted life year is a complicated method used by insurance companies and pharmacy benefit managers to calculate the value of a patient’s life. 

“The QALY methodology places a price tag on the value of living a full year of life in perfect health,” argues Dr. William S. Smith, a Visiting Fellow in Life Sciences at the Pioneer Institute in Boston. “The greatest flaw by far in the QALY methodology is the subjective threshold value attached to a year of perfect health.”

Healthy patients get a perfect score, while patients with disabilities, chronic conditions and rare diseases — even after receiving treatment — are valued at a lower amount of value. 

“Use of the QALY becomes downright life-threatening when it is used to justify arguments that it’s not “worth it” to treat people with cancer using new drugs that have recently come to market, solely based on the expense of these drugs and the assumption that a sick person’s time is worth less,” points out cancer survivor Jennifer Hinkel, a health economist who advocates on behalf of patients. 

H1088: Legislation to Protect All Patients

QALY’s biggest proponent, the Institute for Clinical and Economic Review, encourages insurance companies to reduce all patients to this dollars and cents calculation to determine which patients get covered – and who is left without treatment. It’s that rationing of care, which has inspired Massachusetts lawmakers to take action.

Massachusetts H1088

“I don’t think rationing care, in particular prescription drugs, to the sickest and oldest patients should be a formula that’s used,” State Representative Anthony Puppolo told MassLive’s Shira Schoenberg earlier this year.

This week, the Massachusetts State Joint Committee on Financial Services will hold a hearing on Puppolo’s legislation. Wilcox’s group, Patients Rising, is encouraging patients in Massachusetts to take action by contacting their state representatives in support of H1088.

“We know we’re outmatched, facing the billion-dollar insurance industry,” said Wilcox of Patients Rising. “But, patients have incredible power when we stand united and work together to reform health care.”

Take Action: Support Massachusetts Bill: H1088

  1. Contact MA State Representatives: Send a message to members of the Joint Committee on Financial Services and your state representative in support of H1088.
  2. Post on Social Media: Get the word out in support of H1088 by using hashtags, #ICERWatch & #H1088.
  3. Share Your Story: Have you been denied access to care because of an insurance barrier? Share your story with Patients Rising.