Everyone is in favor of quality healthcare, but there seems to be little consensus on how to value it. The quality-focused organizations have done an excellent job in bringing this question forward, and they attempt to provide some objective measures. Still, challenging questions remain largely unanswered, including agreement on the value of a quality-adjusted life year (QALY; with a range of $50,000-$150,000+) and on utility measures, as well as comfort with comparing therapeutic categories.

Additionally, after we have considered whether a new therapy is reasonable to provide based on the price as compared to QALYs, we are then faced with the question of what is the short-term budgetary impact. A product may score well as far as QALY, but can still be deemed unaffordable—particularly when the benefit falls beyond the ability of the original payer to recoup.

A third challenge in our present system is that patients, providers, payers, and manufacturers all have different views with respect to what constitutes quality care. Broadly speaking, quality care, from the patient’s standpoint is simply getting better, at a reasonable cost, without “hassles.” For the provider, it is offering the best care to an individual patient and being reimbursed for doing so. Payers view of quality is providing care for a population, while staying within budget. Finally, manufacturers view quality as bringing innovative products to market to satisfy unmet needs.

Under the current system, payers develop utilization management (UM) approaches they feel are reasonable. Yet UM approaches create access issues for patients and adverse relationships with providers and manufacturers. Providers attempt to give the best care possible to their patients without seeing the budgetary impact of attempting to manage a population. Manufacturers are troubled when the market does not view their R&D investment and improved care offering as worth the price, or restricts it to a certain population.

There needs to be an attempt to align on the meaning of quality. A component of this may be agreement on the value of a QALY, and how it is determined. In addition, payers need to accept, and pay for, some level of indirect cost value as it is unlikely that a new product’s cost can be completely offset by reductions in other direct costs.

Manufacturers should provide as much transparency as possible into their pricing, and should continue to work with payers to appropriately define an eligible patient population.

There is no single or simple solution that will put our industry on the path to a quality-driven care system, especially given our compartmentalized and cost-driven reimbursement system. What is possible is taking incremental steps that can lead to improvements for all.