Thursday, April 2, 2015

Quality of Life and Quality Adjusted Life Years (QALY)

What is Quality of Life and how is it related to Standard of Living? How should Health-Related Quality of Life play into decisions by individuals, health insurance plans, and government subsidized health care decisions? In particular, how are Quality Adjusted Life Years (QALY) calculated and used to approve or disapprove a given medical procedure by a government or private insurance system?

These are important questions that can have no definitive answers. However, they are well worth discussing in a collegial, rational, and fact-based way.

I presented this Topic to The Villages Philosophy Club in 2012 and updated it for a presentation on 3 April 2015 to the same group. Our meetings draw around 50 people, mostly retirees in their 60's, 70's and 80's.

Participants evaluate which beneficial factors in the "PERSONAL", "PEOPLE", and "THINGS" categories they judge to be the most important factors leading to high Quality of Life. They also use a questionaire called "EQ-5D" to estimate their individual Health-Related Quality of Life levels.

We then discuss the results and the implications for making individual Health Care decisions.The results of our selections and evaluations in 2012 are posted below.

You may view and download the updated, 2015 PowerPoint slides here.

Also see:
END OF LIFE Honest Brokers, not "Death Panels".

"Runaway Trolley" applied to END OF LIFE issues.


After researching this question on the Internet, and thinking about my own country, community, family, and life, I came to the conclusion that Standard of Living is only one contributor to a high Quality of Life. It is definitely possible to live at a moderate Standard of Living so long as you have other beneficial factors in your life. I came up with a list of some 21 beneficial factors, seven having to do with PERSONAL aspects of our lives, seven with PEOPLE in our lives, and seven with THINGS in our lives, as follows:
⃝ Higher Education and Knowledge
⃝ Honest, Hard-Working Reputation
⃝ Satisfying, Rewarding Career
⃝ Travel, Hobbies, Recreation and Leisure Time
⃝ Robust Health and Long Life
⃝ Emotional Well-Being
⃝ Strong Religious Faith

⃝ Loving Parents, Grandparents
⃝ Loving Spouse, Children, Grandchildren
⃝ Loving Siblings and Extended Family
⃝ Great Teachers, Clergy, Bosses, …
⃝ Loyal Friends and Good Neighbors
⃝ Cooperative, Competent Co-Workers
⃝ Competent and Friendly Service People
⃝ Freedom and Human Rights
⃝ Stable and Secure Finances
⃝ Comfortable, Safe Home and Community
⃝ High-Tech Electronics and Entertainment
⃝ Fine Food, Fancy Furnishings, High Lifestyle
⃝ Excellent Healthcare
⃝ Golf, Swimming and other Sports Facilities


During my presentation to The Villages Philosophy Club in 2012, nearly 50 people participated in the survey. Each member was asked to vote for his or her top ten items and the scores were tallied and are graphed below to determine the most important in each category and the most important ten in the whole list.

The top "THINGS" items were:
-Freedom and Human Rights, and (tied for second place)
-Stable and Secure Finances, and
-Excellent Healthcare

The top "PERSONAL" items were:
-Robust Health and Long Life, and
-Emptional Well-Being

The top "PEOPLE" items were:
-Loving Spouse, Children, Grands, and
-Loyal Friends, Good Neighbors

The overall top ten items were the ones with their numbers highlighted in pink:

They are:
1-Robust Health and Long Life
2-Freedom and Human Rights
3-Stable and Secure Finances
4-Excellent Healthcare
5-Loving Spouse, CHildren, Grands
6-Comfortable/Safe Home/Community
7-Emotional Well-Being
8-Loyal Friends, Good Neighbors
9-Travel, Hobbies, Recreation, leisure
10-Loving Parents, Grandparents


The Human Development Index (see
2014_UN_Human_Development_Report)is a 2014 UN publication that considers life expectancy, literacy, education, standards of living, and other aspects of Quality of Life to come up with a score for each country. Not surprisingly, the highest levels are found in the US, Canada, Western Europe, Japan, Australia, Chile, and Argentina. The lowest in Central Africa and parts of Asia.

The 2013 Where to be born index (formerly Quality of Life Index in 2005) 
(see for 2013 update) by the respected British magazine The Economist . They consider: 
Healthiness: Life expectancy at birth
Family life: Divorce rate
Community life: High rate of church attendance or trade-union membership
Material well being: GDP per person
Political stability and security: Political stability and security
Climate and geography: Latitude (warmer and colder climates)
Job security: Unemployment rate
Political freedom: Political and civil liberties
Gender equality: Average male and female earnings

Again, the US, Canada, Western Europe, Japan, and Australia get high scores, but, surprisingly, the top country is Switzerland (was Ireland in 2005 version). The US comes in 16th, between Germany and the United Arab Emirates (was 13th, just after Finland and ahead of Canada in 2005 version).

The Happy Planet Index (see is a 2015 update of the 2012 effort that "is not a measure of which are the happiest countries in the world: [but rather a] Measure of the environmental efficiency of supporting well-being in a given country, and of the Subjective life satisfaction, life expectancy at birth, and ecological footprint per capita."

The US comes in at a dismal  #105 in the 2015 rankings, and is in the worst category along with much of Central Africa and Russia. The best three countries in the 2015 ranking is Costa Rica, with a "Happy Planet Index" that is twice that of the US.


How should Quality of Life impact health care decisions? Government agencies, including the US Centers for Desease Control and Prevention (CDC) and the UK National Institute for Health and Clinical Excellence (NICE) have considered this question for decades, and their decisions are currrently affecting your health care availability, and will do so more and more in the future.

The US CDC website (see has links to many Health-Related Quality of Life pages, as does the UK NICE website (see

Health-Related Quality of Life is measured by several different questionaires, inluding the SF-36 and EQ-5D. The SF-36 (see consists of 36 multiple-choice questions. The EQ-5D (see has five multiple-choice quesitions. The result is a personal score that ranges from 1 (for perfect health) to 0 (for death). It is possible to score as low as -0.5 (worse than death).

In 2012 the members of The Villages Philosophy Club took the EQ-5D survey and the average personal score was 0.88, indicating a pretty healthy group. Around 40% of us reported PERFECT HEALTH with a score of 1.0. About 30% reported NEAR-PERFECT HEALTH with a score of 0.88. About 22% (including me) reported the next level down with a score of 0.76. About 4% reported a score of 0.62, and about 2% each reported 0.47 and 0.33.

When a health care decision is to be made between alternative treatments, consideration is given to an estimate of the level of Health-Related Quality of Life that will most likely result from each treatment alternative, as well as an estimate of how long the patient is likely to live if given that treatment. The result of multiplying Health-Related Quality of Life by Years of Life is called the Quality Adjusted Life Years (QALY).

In the UK, if a given treatment alternative costs less than about 30,000 pounds per QALY, and if the doctor and patient want that alternative, it is approved and paid for by the National Health Service. If the desired alternative is more expensive than about 30,000 pounds per QALY, it is denied, and a lower cost (and more cost-effective) alternative is approved. 30,000 pounds is equivalent to about $40,000 - $50,000.

Please feel free to comment. I would love to have an interactive discussion. Click on "Comments" just below my name, type your comment, then choose "Name/URL" and enter your name or nickname (URL not required), and then "Publish". If you are not an "Authorized Author" it may take a day or so for me to moderate your comment and then it will appear.)

Ira Glickstein


Jay Kaplan said...

Although my wife and I missed your April 3rd presentation, the information above was quite interesting. We would like to see the results from the 2015 meeting and how they compared to the previous meeting.

We hope that you will be giving another talk on QALY at another venue. We always enjoy your presentations and try to clear our busy schedules to attend.

Jay Kaplan

Joel Fox said...

I dislike the notion of QALY because it's dishonest. It creates a smoke-screen for what we used to call "socialized medicine." The failures of the European and British systems are well known. The use of QALY and other such computation devices lend an air of scientific respectability to yet another mechanism which undermines freedom of choice so well described by F.A. Hayek in "The Road to Serfdom." We, as a nation, need to have the discussion that starts with a definition of the difficulties with the free enterprise system of medicine and methods by which we could get more competition.

Ira Glickstein said...

Jay: Thanks for your kind comments. I did not do a new survey of the large crowd (over 80 people) at the April 3 meeting, but most seemed to generally agree with the results I presented from 2012.

Joel: THANKS for your critical comments regarding QALY. I hope others join in with similar substantive comments leading to something like those dozens-long discussions between you, Howard Pattee, and me that still exist in cyberspace and still generate a surprising amount of traffic, averaging a bit over 100 page views a day.

OK, I am not fond of "socialized medicine" and other basic undermining of our mostly-successful (compared to most other contemporary nations) mixed market-enterprise and government subsidized system).

However, when it comes to medical care, paid for by private insurance pools (to which employers and individuals pay premiums) and subsidized by government social programs (paid for out of social security and taxpayer dollars), there HAS TO BE (IMHO) something like a QALY system to prevent abuse of the system by greedy doctors and hospitals rendering expensive service to sick, often old, and sometimes terminally ill patients.

Milton Friedman said (something like), "When Mr. A (in this case the medical establishment) uses Mr B's (workers, taxpayers) money to benefit Mr. C (patient in medical establishment), there is NO LIMIT TO HOW MUCH MONEY WILL BE WASTED."

What is YOUR alternative to insurance pools and Medicare using something like Quality-Adjusted Life Years to restrict the alternative care decisions of doctor and patient to choices that are cost-effective?

If some rich person is using his or her own money to pay for medical care, I don't care what they choose to spend.

But, when an ordinary person uses money out of an insurance pool or taxpayer funding THAT I HAVE PAID INTO (AND DEPEND UPON FOR MY FUTURE CARE, I want to be assured that we don't spend excess money on expensive Alternative A when Alternatives B and C are nearly as effective for a lot less expensive.

I understand we spend more than half the dollars we will every spend on health care during the last year of our lives. That is not sustainable, and also cruel to the recipients of painful surgery who will most likely die within the year.

So what is YOUR alternative to QALY?


Joel Fox said...

Hi Ira, You repeat a statement "I understand we spend more than half the dollars we will every spend on health care during the last year of our lives." The proponents of QALI have repeated this phrase unchallenged for a long time. It conveys an image of ancient people sucking up public funds unnecessarily. Cleverly worded, It neglects the fact that almost everyone is included in this statistic whether you die at 100 or twenty. My mother at age 42 consumed the majority of her life's medical expenses when she died on the operating table. Of course, it was the last year of her life! Her QALY score would have been very high. Using the words "LAST year" is automatically biased and the result appears shocking, because whatever kills you is usually serious and expensive to fight. I'll have some suggestions in my next comment.

Joel Fox said...

You asked for alternatives. One would be to return to the days where we paid for services as individuals- no government-no insurance. The doctor was the wealthiest guy in the neighborhood and healthcare was affordable but expensive for most people. You only went to see the doctor if you really needed him. If you guessed wrong about your needs, you got very sick and/or died. You were your own "death panel." Then health insurance became popular as a fringe benefit in labor contracts. Going to the doctor was still expensive enough to cause people to grin and bear it. Competition between doctors kept prices low and research into new methods was at a minimum compared to the present. Health was an individual matter except when there were epidemics like the great influenza plague, polio and whooping cough. The intervention of government was necessary when public health required that vectors or carriers be isolated. In other words, it's not difficult to distinguish between public health and private health. They can be treated differently.

Joel Fox said...

The above distinction between public and private health, suggests a funding scheme. Suppose that all public health matters were completely funded by the government whether you are rich or poor. The money would come from the general tax fund just like the military budget. This protects the general population. All other disease would be treated privately by whatever private means might be available. The laws of supply and demand would function well and bureaucrats would not accrue more power. Private insurance would still be possible. Heart medication would be a private matter not to be government funded, but HIV drugs would be funded fully, but patients would be isolated as with other communicable diseases.

Ira Glickstein said...

Joel: I am, in general, sympathetic to your statement that:

"Health was an individual matter except when there were epidemics like the great influenza plague, polio and whooping cough. The intervention of government was necessary when public health required that vectors or carriers be isolated. In other words, it's not difficult to distinguish between public health and private health. They can be treated differently. ...

"Suppose that all public health matters were completely funded by the government whether you are rich or poor. ... from the general tax fund ... All other disease would be treated privately by whatever private means might be available. The laws of supply and demand would function well and bureaucrats would not accrue more power. Private insurance would still be possible."

OK. Say, under your favored scheme, outlined above, you were a middle-aged person responsible for the health decisions and costs for yourself, your loving spouse, child, and aged grandparent, who all had a normal health level and life expectancy for their respective ages.

Then, one of them suffered a serious, life-threatening accident or illness and you had to choose between three general health care alternatives:

Intervention "A", the most complex and expensive, requires extensive surgery or drug treatment that is potentially painful with an extended recovery period. If successful, "A" would restore the patient to 90-95% of normal health quality of life and life expectancy for his or her age.

Intervention "B" is moderately complex and costly with a shorter recovery period. If successful, "B" would restore the patient to 70-80% of normal health quality of life and life expectancy for his or her age.

Intervention "C" is palliative care to make the patient as comfortable and pain-free as possible. However, health quality of life and life expectancy would be considerably less.

Obviously, all of the above is very general and predicted outcomes are necessarily uncertain. Yet, YOU, in consultation with the patient and doctor, MUST weigh the probabilities and make the decision, and (under your assumption of private funding) PAY for the treatment (or live with whatever restrictions might be imposed by the "Ford" or "Cadillac" private health insurance plan you purchased).

So, how would YOU approach such a decision? It seems to me that in the above circumstance, I would consider the probable pain and suffering imposed by the treatment regime, the probable health quality of life and life expectancy that might result, and the relative cost-effectiveness of the choice. I would most likely choose something like "A" for my beloved child, "B" for myself and my loving spouse, and "C" for my dear aged grandparent.

In other words, I would use a variation of the Quality-Adjusted Life Years (QALY) scheme. How about you?

But what if I (or you) was a rich as, say, Bill Gates? Would that change the choices? Perhaps I would upgrade to "A" for myself or my spouse, but I would most likely, out of compassion alone (since cost would be no object), still choose "C" for my dear grandparent.


Joel Fox said...

Hi Ira, The problem is that you probably wouldn't have the choice between a low tech intervention and a high tech system. The free enterprise system that we have now encourages resaerch and new development, but the rationed system does not. Thats why the rich and powerful come to the US for treatment. That's why people die while waiting for heart operations in Britain even if they qualify on a "merit" basis.

Ira Glickstein said...

Joel: Rather than say which intervention you would choose if you were responsible for your dear elderly grandparent (or parent) and if cost was no object because you were as rich as Bill Gates, you answered that, absent our free enterprise system, the high-tech intervention would not be available (presumably not even for Bill Gates's relative).

OK, I understand and agree that if the US had a QALY (rationing) system for PUBLIC funding of health care, that would put a damper on the development of some high-tech interventions.

However, so long as multiple PRIVATE insurance plans were available, the rich could choose plans with more generous QALY limits, of course at higher premiums. Or, the rich could simply pay cash to hospitals here in the US or abroad. I have absolutely no objections to more generous QALY limits so long as they are PRIVATELY funded and do not increase my health-care insurance premiums

A potential benefit of a QALY system would be that it would encourage medical researchers and providers to develop more cost-effective treatments for the most prevalent conditions if that would drop the costs under QALY limits and make them available for PUBLIC and standard PRIVATE insurance funding.

I have just experienced a prime example of what, to me, seems a waste of YOUR money to benefit ME and the Physical Therapist who recently treated me. As you know, I was diagnosed with Parkinson Disease a few years ago. I am on Dopamine, a relatively inexpensive drug that works fine for me. After the original diagnosis, my neurologist prescribed Physical Therapy (PT), and I took about a dozen hours of it over a couple months and thought it worthwhile. Well, after three additional years, my neurologist prescribed another round of PT, which I have just completed. It turns out that, with Medicare and our AARP insurance, there was no cost to me at all. I had no idea what the PT was costing until I asked and found out it was costing YOU (and your fellow taxpayers and insurance plan funders) over $2000 for each of my PT series!

The PT therapists were, IMHO, quite competent and they really gave me the hours that were billed, and there was some benefit. HOWEVER, if I personally had to fund the PT I received, I would NOT HAVE DONE SO.

That proves Milton Freedman's statement that when Mr. A (Medicare, insurance company and PT provider) uses Mr. B's money (taxpayer and major insurance premium payer) to benefit Mr. C (Ira, in this case), there is no limit to the amount of money that may be wasted.

Please note that there was no lying or cheating or misrepresentation in the case of my PT. I really have the disease, the PT was of some (small) benefit, and the providers were competent and caring, using good equipment and techniques. Of course, as we know from many 60 Minutes and other investigative TV and newspaper reports, there is quite a lot of outright cheating in this area.

Ira Glickstein