How Should Willingness-to-Pay Values of Quality-Adjusted Life-Years Be Updated and According to Whom?

Before updating any willingness-to-pay (WTP) per quality-adjusted life-year (QALY) threshold, a few points must be recognized. Ethical justification for using WTP thresholds and QALYs lies in incorporating the preferences of those whose treatment could be affected by resulting resource allocations. For WTP thresholds, such justification depends on the sufficiency of a match between a group-members of an insurance pool from which health care payments and services are drawn-and those whose health care is potentially affected. For QALYs, that justification depends on eliciting the right persons' preferences to inform quality-adjustment ratings; on balance it should be from those who have the conditions being rated. Because the value of simply being alive is not adequately accounted for, how life extension and quality improvement are combined in constructing the QALY is its most significant shortcoming as a measure. Although updating WTP thresholds might be better than not updating them, this manuscript suggests why drawing on a less fundamentally flawed concept than the conventional QALY is more important.