How HTA-based price controls could worsen health outcomes and health disparities

Concerns about the cost of health care have led to calls for the use of health technology assessments or HTAs by the federal government. This would allow government agencies to make important decisions about patient access to health care based on their determination of the value of new tests and treatments. In this series, we’ll explore how this controversial practice:

• Ignore differences in diverse populations
• Limit access to beneficial treatment options
• Reinforce — rather than reduce — health disparities

Value assessments are one of many tools that support better value in health care. These assessments need to reflect what matters to patients, address health disparities, be open and transparent, look holistically at services provided across the health care system, support doctor-patient decision-making and be based on rigorous science.

Unfortunately, health technology assessments, or HTAs, do not fit those parameters. By relying on rigid averages, HTAs lead to one-size-fits-all access restrictions, which can discriminate against disadvantaged communities and undermine efforts to advance health equity.

Many forms of HTA rely on the controversial quality-adjusted life years, or QALYs. This metric can lead to inherent biases that undervalue treatments for individuals within marginalized communities, such as communities of color and patients with disabilities. Here’s how that oftentimes happens: 

• Those in lower-income communities and communities of color can experience lower life expectancy and greater disease burden due to underlying health inequities. As a result of disparities in life expectancy, researchers found that QALY-based methods result in the value of a life-saving treatment for Black patients being automatically up to 10% less valuable than for white patients.
  
  
• Similar problems occur in people with disabilities. QALYs can assign a lower value to health improvements for people with disabilities because QALYs erroneously assign them lower total “quality of life” potential.

By ignoring population diversity, HTAs can reinforce health disparities and result in access barriers that make it harder for underserved populations to receive the treatments they need. Researchers recognize these shortcomings in current HTA methods and are encouraging steps to close those gaps:

• The Innovation and Value Initiative: “Structural deficiencies in the models that underlie value assessment have perpetuated health inequities. Communities of color and other groups are generally not represented in the data used to make health care decisions, routinely disadvantaging them.”
  
  
• Researchers at RAND: “The current cultural moment in medicine makes wider acceptance and use of more inclusive methods in HTA possible. We believe seizing this opportunity will fortify the ethical foundations of our work. We are calling on researchers to stop business as usual and to apply an inclusion and an equity lens to all we do…”

Value assessments and HTAs should not be used by health plans, government agencies or other payers to impose one-size-fits-all standards or deny needed care to patients. Instead, all stakeholders need to do more to ensure that health care is delivered equitably. Investing in better data that recognize disparities in health outcomes can help. Ultimately, we can move toward a value-driven health care system that works better for patients by reflecting what matters to all patients.

Learn more at phrma.org/policy-issues/value-assessment.