I worked in a hospital for 13 years. The economic incentives for the current system are quite perverse.
The FDA has no cost constraints and so maximizes safety instead of QALYs.
Medical equipment and drug manufacturers maximize profit and so fill the highest margin niches first instead of maximizing QALYs.
Radiology and lab services are lucrative and separate themselves from clinical providers to maximize profits instead of QALYs.
Individual physicians and especially surgeons can maximize profits by having their own practices vs. hospital or clinic environments where coordinated care maximizes QALYs.
Hospitals and clinics and especially ERs, cancer treatment, and skilled nursing facilities try to make ends meet with inpatient population and try to hold on to outpatient surgery, radiology, and lab services to make ends meet while providing whatever level of coordinated care they can, but still optimizing for profit over QALYs.
Insurance companies maximize profits by building actuarial plans that stratify patient populations by plan cost, skewing the burden of healthcare costs to the unemployed, underemployed, and low wage earners. A patient becoming uninsured is an economic win for insurance companies and employers. QALYs are proxied by cost/patient/year for anyone managing to stay insured which ignores deductibles, co-insurance and other out of pocket pay.
Medicare and medicaid programs are left to pick up the pieces by trying to piece together effective care with compensation restricted by arbitrary budgets and arbitrary service providers (many specialists, independent physicians, and facilities flatly refuse medicare/medicaid patients).
Actual patients have no clue how any of this works and end up with a pile of bills they try to pay off or if they know the trick they negotiate with the healthcare provider to settle for something slightly above the ~2% face value of debts written off to debt collectors who will hound sick people and their families incessantly.
Maximizing QALYs is hard enough in a centralized single-payer or universal healthcare system. Almost nothing in the U.S. healthcare system is aligned with that goal.