From QALYs to Equal Value Life Years: Is Anyone Making the Shift?
Antony P. Martin and Peter J. Neumann
Over the years, Congress has prohibited Medicare from using QALYs or similar metrics in coverage and reimbursement decisions. For example, the Affordable Care Act of 2010 [1] forbids the use of any metric that “treats extending the life of an elderly, disabled, or terminally ill individual as of lower value than extending the life of an individual who is younger, nondisabled, or not terminally ill.” In the 2022 Inflation Reduction Act, Congress uses similar language to restrict the Centers for Medicare & Medicaid Services (CMS) from using any such metric in its drug price negotiations [2].
As a way of preserving a value-based summary measure in light of such prohibitions, the Institute for Clinical and Economic Review (ICER) introduced the equal value life-year (evLY) metric [3]. By assigning equal value to each additional year of life gained, regardless of an individual’s health status, the evLY offers an alternative to QALYs intended to align with anti-discrimination principles.
Since September 2019, ICER has included cost-effectiveness analyses (CEAs) using evLYs alongside CEAs using QALYs in its health technology assessment (HTA) reports [3].
But has anyone else adopted the evLY? We conducted a PubMed search as of October 6, 2025 to evaluate the question. We used the search terms “evLY” and “QALY,” restricting the search to studies focused on United States populations and settings. Our search found only 60 results referencing evLY since 2020, compared to over 3,568 results for QALYs or about 1.7% of the total. A separate preliminary search of published US-based cost-effectiveness analyses yielded only three results between 2020-2023, compared to 1,332 cost/QALY studies in the same period.
How to interpret the limited use of the equal value life year to date? Does it simply reflect the perennially slow uptake of new concepts, or a broader view that it is an inadequate measure alongside the QALY? Or does it reflect the fact that most US-based CEAs are intended to inform private payers, who are not restricted from using the QALY, and that most industry-funded CEAs, even those focused on US settings, are intended to inform global conversations, where the QALY is not restricted?
While QALYs are criticized for potentially discriminating against individuals with disabilities or chronic conditions [4], there are good arguments in favor of retaining the metric [5]. Moreover, even as they address some limitations of QALYs, evLYs have their own shortcomings – e.g., they do not assign additional value to health technologies that also improve HRQoL during the period of life extension [3].
Is the evLY destined to remain in the shadow of the QALY? Time will tell. But for now and seemingly into at least the near future, QALYs seem destined to remain the dominant summary measure used globally for assessing preferences in cost-effectiveness analyses.
References
- U.S. Congress. (2010). Patient Protection and Affordable Care Act, § 1182, p. 623. Public Law 111-148. Retrieved from https://www.govinfo.gov/content/pkg/PLAW-111publ148/pdf/PLAW-111publ148.pdf [Accessed: 10/08/2025].
- U.S. Congress. (2022). Inflation Reduction Act of 2022, Pub. L. No. 117-169, 136 Stat. 1818. Retrieved from https://www.congress.gov/117/plaws/publ169/PLAW-117publ169.pdf [Accessed: 10/08/2025].
- Campbell JD, Whittington MD, Pearson SD. An Alternative Measure of Health for Value Assessment: The Equal Value Life-Year. Pharmacoeconomics. 2023;41(10):1175-1182. https://doi.org/10.1016/j.jval.2023.11.009
- Ubel PA, Nord E, Gold M, Menzel P, Pinto-Prades JL, & Richardson J. (2000). Improving value measurement in cost-effectiveness analysis. Medical Care, 38(9), 892–901. https://doi.org/10.1097/00005650-200009000-00004
- Neumann PJ, & Cohen JT. (2018). QALYs in 2018—Advantages and concerns. JAMA, 319(24), 2473–2474. https://doi.org/10.1001/jama.2018.6072