A Parsimonious Approach to Remediate Concerns about QALY-Based Discrimination

US regulators and payers avoid using quality-adjusted life-years (QALYs) for reasons including concerns about disability and age discrimination. Various modifications of the QALY health utility function have been proposed to address discrimination concerns but are unintuitive to some and appear to alter the usual typical QALY tradeoffs between life expectancy and quality of life. I assert that it is unnecessary to further modify typical QALY tradeoffs to address discrimination concerns because, while discrimination and inequality are distinct concepts, aversion to them can be represented by the same mathematical formulation. Accordingly, formulating QALYs based on inequality aversion, as is sometimes done in distributional cost-effectiveness analyses, may be used to counter disability and/or age-based discrimination concerns. I illustrate using a hypothetical example of a lifesaving therapy, applied across varying ages and baseline disability levels, and adjusted for varying levels of the Atkinson inequality-aversion parameter epsilon (ε). I conclude that adjusting QALYs for inequality aversion using ε ranging from approximately 1 to 2 may remediate concerns about QALY-based disability and/or age discrimination in some cases. Highlights Important barriers to the use of QALYs in the United States include concerns about disability and age discrimination. Modifications to the utility function underlying QALYs have been proposed to mitigate these concerns, but some find them challenging to consider and/or to apply. Unrelated to these concerns, QALYs have been adapted within the framework of distributional cost-effectiveness analysis to allow consideration of inequality as well as efficiency. I outline how this framework can also remediate concerns about disability and age discrimination.