Rationing Health Care, British Style
posted by Frank Pasquale
Gardiner Harris’s article on drug rationing in Britain will be of great interest to those following health care reform. Here as in many areas of medicine, the British are pretty stingy:
Five years ago, the British health institute recommended more emergency room CT scans of patients suffering from head trauma — forcing hospitals to buy more machines. But the decisions that get the most attention are those involving new drugs. Any drug that provides an extra six months of good-quality life for £10,000 — about $15,150 — or less is automatically approved, while those that give six months for $22,750 or less might get approved. More expensive medicines have been approved only rarely.
Britain’s National Institute for Health and Clinical Excellence (NICE) is at the cutting edge of an evidence-based movement aimed at reducing health care costs and getting value for money. But the Orwellianly named NICE risks scuppering the enterprise if it sets the effective price of life too low, or shrouds its decisions in secrecy. Sadly, there is some evidence it is doing both:
Transparency recently became a high priority, but gaps in the idea of openness remain. At the institute’s first public decision-making appraisal meeting in September, staff members handed a reporter a stack of documents, only to snatch them back moments later. The committee’s chairman, Dr. David Barnett, was so intent on keeping the meeting brief that he told a committee member: “This must be the last question. It must be relevant. Otherwise, you will feel my wrath.”
To analyze the value of the drug that [would likely help about 6000 kidney cancer patients], and the value of three other kidney cancer medicines, the British institute hired a university group that considered how many months the drugs delayed cancer’s progress. The academics got drug prices and calculated the costs of administering them and treating their side effects. Not one of the drugs came close to being worth their expense, the group suggested. In a preliminary ruling in August, a committee from NICE agreed.
The decision caused a firestorm. Twenty-six prominent British oncologists wrote a letter to The Sunday Times saying that the institute assessed cancer treatments poorly and that patients were remortgaging their homes to buy drugs freely available in other countries.
I am going to try to find the studies to see exactly what the claimed flaws are. NICE is attempting to use public funds to direct health care innovation toward interventions that save the most lives at the lowest cost. As its leader says of drug companies, “I want them to produce new drugs for conditions we really need treatments for.”
Some are sure to balk at NICE’s methods, and there are sure to be big political debates over how much we should spend on saving lives. These debates will only become more intense as the possibilities of pharmacogenomics and personalized medicine become clear. We should begin to see efforts like NICE’s less as denials of earned services than as transfers of the responsibility for financing certain forms of medical innovation from the public to the private sector–if NICE takes a cue from the work of David Cutler and others and begins valuing life more adequately.
It’s sad to see rationing done badly, because it will be an important function of any public health care provision. As Niko Karvounis writes,
Excessive medical technology is one of, if not the, major factor driving health care costs in the U.S. In a recent post, Maggie Mahar noted that Peter Orszag, head of the Congressional Budget Office (and soon-to-be Director of the Office of Management and Budget in the Obama Administration) estimates that the proliferation and utilization of new medical technology accounts for somewhere between 38 and 65 percent of the growth in health care spending from 1940 to 1990. That’s huge—and the trend can’t continue. We’re already spending $2.3 trillion on health care every year.
Given the impending $8 trillion bailout, I am not as fast as Karvounis to decry such numbers–particularly if they lead to the professionalization of the caregiving class that Robert Kuttner has advocated. But he is right to say that evidence of concrete gain–not clever marketing–should drive our spending on doctors, drugs, and devices.
December 3, 2008 at 4:14 pm
Posted in: Health Law
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