[The cost per year of life gained: trends and internal contradictions]

Recently, a Dutch advisory committee to the Ministry of Health presented a report proposing criteria for health insurance coverage. A central role has been given to the criterion of cost per quality-adjusted life year (QALY) associated with medical interventions. The proposal is to limit the health-insurance coverage of such costs to 80,000 euro per QALY gained. Previously, 20,000 euro was generally considered a reasonable critical level for QALY-cost, whether for preventive or for curative interventions. Although a higher cut-off-level is now proposed by the advisory committee, recent cardiovascular prevention guidelines propose treatment criteria that are associated with much lower QALY costs, sometimes as low as 1,000 euro. With respect to financial considerations, the central role of QALY costs has been replaced in these prevention guidelines by national health budget implications. For individual patient care, these apparently opposing trends in the role and financial appreciation of QALYs have complex repercussions.