By NextBestFitCover everything clinically effective, without cost thresholds
Ban cost-per-QALY thresholds; cover any treatment shown to work and control cost through price negotiation instead.
Conflicts with evidence-based coverage.
Review ledgerHow this path connects
Concrete changes if chosen
What would actually have to change in law, agencies, payment rules, or systems.
- Ban cost-per-QALY thresholds
Effects
Each effect has its own page: the evidence, the case that it is or isn't a real cost, and whom it affects.
- Central coverage decisions can feel like rationing
Covering treatments shown to work without cost-per-QALY thresholds reduces denials and the perception of a panel deciding who may receive care, while relying on price negotiation to control cost.
- Claim denials
Covering any treatment shown to work rather than applying cost-per-QALY thresholds leads to fewer coverage denials.
- Chronic underfunding by government budgets
Broader treatment coverage raises spending while leaving weaker leverage to control costs through negotiation.
- Raises spending or loosens control over it
Covering effective treatments without cost-per-QALY thresholds raises spending and weakens negotiating leverage.
Who's affected
- People with ongoing or specialist care needs
- Central coverage decisions can feel like rationing: People needing a declined or delayed treatment have no other insurer to turn to.
- Claim denials: Care is delayed or denied, and appeals take time.
- Drug and device makers
- Central coverage decisions can feel like rationing: A declined product loses the whole national market.
- Doctors, nurses, and other clinicians
- Claim denials: Providers absorb unpaid claims and appeal work.
- Taxpayers and public budgets
- Chronic underfunding by government budgets: Restrained health funding limits public spending in the short run.
- Taxpayers and public budgets
- Central coverage decisions can feel like rationing: Declining low-value care holds down public spending.
- Raises spending or loosens control over it: Public budgets pay the added spending.
- Health insurers, brokers, and their shareholders
- Claim denials: Denials lower insurers' medical spending.
- People relying on publicly funded care
- Chronic underfunding by government budgets: Slow public funding growth leads to longer waits.
- Doctors, nurses, and other clinicians
- Chronic underfunding by government budgets: Public budget competition constrains funding for their work.
Where it has been tried
- U.S. Medicare: Covers what is 'reasonable and necessary' and is barred from using QALYs.
- United States: KFF explains that the Inflation Reduction Act prohibits using QALY-based health outcomes evidence in Medicare's negotiation of a maximum fair drug price.Sources: KFF (2024)