The health care debate: Marginal treatments

feb25_mccain_ap.jpg

Sen. John McCain is back on the stump with a “town meeting” style event for health care today.

“You know in England, the NICE (National Institute for Health and Clinical Excellence) has denied treatment for women with breast cancer, and people with Alzheimer’s, and denied life-saving drugs for people with MS,” the former presidential candidate said to a group of mostly senior citizens, the one demographic he won in last year’s election.

True?

Apparently so. And it comes directly from a briefing paper prepared by the conservative Heritage Foundation, which said:

* NICE restricted access to two drugs for Age-Related Macular Degeneration, Britain’s leading cause of blindness.[6] The first drug, Macugen, was completely blocked, while the second, Lucentis, was limited to the approximately one in five disease sufferers who have a specific type of the disorder.[7] Even then, Lucentis was restricted to patients with that type of the disorder in both eyes–and could only be used in the less-diseased eye. In the words of Tom Bremridge, chief executive of the Macular Disease Society, “allowing one eye to go blind before treating the second eye is cruel and totally unacceptable.” Winfried Amoaku of the Royal College of Ophthalmologists explained, “There are differences in action between these two drugs, which may be important in individual cases, and so we do not wish to be limited in our treatment options in this way.”

* NICE limited several Alzheimer’s drugs to use in patients whose disease had advanced from early to middle-stage. Even though doctors argued that starting treatment at the onset of dementia would be most effective in slowing the progression of the disease,[8] NICE decided that patients would have to wait until they became sick enough for the treatments to meet the cost-effectiveness threshold. A charity has taken legal action, accusing NICE of “ignoring totally the proven benefits of the drugs for careers of those with mild symptoms, and grossly underestimating the savings they bring to the state by enabling suffers to remain in their own homes longer. [The charity] accused NICE of implying careers are far better off when the condition of their sick relative deteriorates so much that they are forced to move into a residential home.”[9]

* NICE blocked access to Glivec, a leukemia treatment. Ann Tittley, a 55-year-old patient, was being treated for breast cancer when she was diagnosed with leukemia. After realizing she would be denied access to Glivec even though her physician had recommended she start it immediately, Ms. Tittley wrote a letter to then-Prime Minister Tony Blair. “Glivec was my lifeline, at least it would give me a chance of beating this disease,” wrote Ms. Tittley. “Life is precious…. I appreciate that cost is important, but to deny patients this potentially life-saving treatment on this basis is totally unforgivable and criminal.”[10]

In a June article, the Economist noted the concerns and suggested, however, there are provisions which could prevent them in a reformed health care system:


In America, the drugs and devices lobbies are violently opposed to a NICE-style agency that could issue mandatory rulings. They paint a scary picture of Americans being denied access to life-saving new drugs by faceless bureaucrats. In Britain NICE has come under fire for rulings that limited access to expensive drugs for Alzheimer’s and cancer on the NHS. America could get around this problem by requiring and perhaps even funding studies, but leaving insurers and individuals to decide whether to pay for treatments.

As with many aspects of the health care debate, there’s more to the story. Aricept is the drug NICE originally kept off its formulary, according to the New York Times. It costs about $2,200 a year and some Medicare drug plans pay for it; some don’t, says The Times’ Caring and Coping blog.

Daniel Callahan, a bioethicist at the Hastings Center, says the drug — and several others that are linked to the anecdotes above, can slow the progression of a disease, but only for a short time and have only marginal benefits given their cost. It’s a question, he says, Americans don’t want to ask or discuss.


The most generic way this is done is to declare that life is priceless and even to pose such a question is immoral; and so also with the idea of rationing beneficial treatments. Considerations of cost should simply have no place in our reform calculus.

But there are more subtle ways that cost are sidelined in the reform debate. One of them is the powerful role of the pharmaceutical industry, also taken up in the New Old Age. By treating any consideration of cost as a threat to innovation, both the profit motive is protected (patents run out), and the American romance with endless medical progress is pandered to.

At the end of the debate where McCain traveled today, each side — proponents and opponents — can approach the same issue with two different questions.

(1) Why should the government tell me what drugs I can have when it should be my choice?

- or -

(2) Why should taxpayers — or the other members of your insurance pool — pay for a drug for you that has little value?

Pick your poison.

(AP Photo/Matt York)

  • bsimon

    The flaw in the argument, of course, is in ignoring wether patients’ existing coverage would pay for the same drugs. Whether you are insured by the gov’t, buy private insurance or pay your own way out of pocket, someone, somewhere is making a cost-benefit decision about whether a treatment is worth the cost. Conservatives have very effectively demonized the government such that nobody wants anyone associated with gov’t making such decisions. Yet they seem to have no qualms about handing the same decisions to an actuary working for a for-profit insurance company.

  • kates

    // (2) Why should taxpayers — or the other members of your insurance pool — pay for a drug for you that has little value? //

    what about the use of a placebo? who’s to say what actual value someone might get out of a drug?

  • Bob Collins

    //who’s to say what actual value someone might get out of a drug?

    That’s the issue. The debate really isn’t about a decision to get a drug or take a drug. The issue is about who pay for it and depending on whom that is, what decisions/inputs that person /organization/government has in whether it’s worth the money.

  • BJ

    I love that many people have made the agument that private insurance is better. I think bsimon has it right on the head with

    ” Yet they seem to have no qualms about handing the same decisions to an actuary working for a for-profit insurance company. “

  • Minn Whaler

    Or (3) Let’s not provide any health coverage option for people unable to afford it themselves or lose it when they are laid off and then we’ll save tons of money while they wait until they are in critical condition so that a hospital won’t legally be able to turn them away, have a very slim chance of saving them hence thinning out the workforce which will help unemployment figures to go down.

  • Bob Collins

    Given that pharmaceutical companies create demand at the patient level for a drug via TV advertising (don’t let the warnings scare you), I wonder if there’d be the same amount of marketing if there were a system in place — or if the question was even asked — that would make it easier for people to understand just effective — or not — these drugs are.

    True, perhaps, that’s information that should come in consultation with a doctor, but that doesn’t change the fact that demand is created by TV ads, for example, showing two people in individual bathtubs in a meadow on a mountainside.

  • BJ

    you know the Alabama Policy Institute

    said “In addition, an article in The Vancouver Sun reported that “… patients needing neurosurgery, treatment for vascular diseases and other medically necessary procedures can expect to wait longer for care.” “http://alabamapolicy.org/gary_blog/article.php?id_art=372

    Seems like everyone say people have to wait for care in Canada.

    Is it because everyone has coverage and clogging the system?

    and

    Not related to rationing, just simple if 10 people in line for something that takes a day to do, the wait is 10 days?

    so

    If I am the only person in line it takes 10 days before the “system” lets me see a doctor?

  • Bob Collins

    I think those are the sort of anecdotes we’re hearing a lot of. But I wish they’d compare it to the U.S.

    Midmorning’s hour on health care today was quite interesting with a comparison and also the notation that every country thinks it has the best health care.

    My wife needed some pretty important care. But whens he called the specialist to whom she was referred, it was a three month wait for an appointment.

    That’s the sort of thing I want to hear about in real terms. If I need some care, how long do I wait in THIS system vs THAT system?

  • matt

    “Yet they seem to have no qualms about handing the same decisions to an actuary working for a for-profit insurance company. ”

    If you suspect that the push for healthcare reform is leading to a single payer system (through the back door of the current proposals) then the this quote takes on a new meaning. Currently if my health insurer will not pay for a treatment I have several choices – look for another insurer (even if that means switching jobs), purchasing supplemental insurance, paying for the treatment out of pocket. Under a single payer plan some of these options are limited – and I suspect even the option of paying out of pocket deteriorates as the same govt that controls what insurance will pay for controls what medications are legal.

  • JSmith

    matt

    Under a single payer plan your options are no more limited. You simply purchase private supplemental insurance that covers the desired treatment. And it has the added benefit of you not needing to switch jobs (unless your prospective employer offers a supplemental insurance that they would pay a good percentage of the costs for).

    It’s done this way in basically every country with a single payer model. It’s just like now, in the end, except you have a fallback plan instead of having to accept simply no care at all.

    You’re misrepresenting the government boards in these cases. They simply said, “We won’t pay for this drug as it’s not very effective.” Nowhere did they say, “This drug is now illegal to obtain in this country.”

  • kennedy

    Single payer coverage already exists in the US as Medicare. Due to burdensome paperwork requirements and limitations on reimbursement, many caregivers are opting out of the program. Along with a shrinking pool of caregivers comes a growing pool of participants. Without some sort of reform, I expect performance of this system will decline dramatically over the next few years.

    The same people who want to stay on the current track today for fear of change will be advocating change once their own personal health care options get bad enough.