NYTimes Article On Health Care Reform and Why Care Must Be Rationed

[MitchMiller]

Sorry, this is a five page article so I"m only posting the link.  Thought those following the health care reform debate, but not monitoring NYTimes, might be interested.

http://www.nytimes.com/2009/07/19/magazine/19healthcare-t.html?ref=health

[Inchlingblue]

Excellent article by a brilliant thinker, Pete Singer. Thanks for posting.

[Luke]

Very good article.

[GSOgymrat]

Thanks for posting the article. It was very interesting. I don't have a problem with rationing healthcare because to me it is better to have rationed care than no care at all.

[mecch]

If rationing means not springing for 100,000 treatments that extend lifetime a few weeks or months, I am all for it.
But, who decides what is acceptable or not? A board of doctors and statisticians?  Religious leaders?  Epidemiologists?  It should not be insurance representatives!!!!  And, the latter seem to be just too powerful in the USA. 

[PozBrian]

Great atricle! I wish more public debates were at that level of sincerity and candor.

[GSOgymrat]

Of course just because insurance or the government won't pay for treatment doesn't mean you can't get the treatment if you have the money. For example, my insurance won't pay for me to have Sculptra, PMMA or any other cosmetic treatment for lipoatrophy so I went to Brazil and paid out of pocket. The government is not going to be to pay for everything but I feel everyone in the US should have access to at least basic affordable healthcare. I think the best system for the US is as he describes in the article: everyone has "Medicare" and insurance is available to supplement and provide more options.

[Luke]

If rationing means not springing for 100,000 treatments that extend lifetime a few weeks or months, I am all for it.
But, who decides what is acceptable or not? A board of doctors and statisticians?  Religious leaders?  Epidemiologists?  It should not be insurance representatives!!!!  And, the latter seem to be just too powerful in the USA.  

Well, here in England we have NICE, the National Institute for Health and Clinical Excellence (http://www.nice.org.uk/), which was mentioned repeatedly in that article. It is a government funded body (composed of healthcare professionals, patients, carers and academics) which consults with the public and publishes clinical evaluations of whether particular treatments should be considered worthwhile by the National Health Service on the basis of dispassionate appraisals of efficacy and cost-effectiveness in various circumstances.

If NICE recommends a treatment, then it is a treatment that you are legally entitled to. If they don't: you may still be offered it, but can't demand it .. or you can pay for it privately. Quite counter intuitively, they actually tend to approve far more procedures than most private insurers do - in part because the fact that they are there, combined with near monopoly buying power, has created an environment where the drug companies charge the National Health Service substantially reduced rates for their drugs to ensure that they pass the 'value for money' test. Or, in the case of the prohibitively expensive cancer treatment, which only extends life by a matter of months, only charge for the first round of treatment and supply all future rounds of treatments free of further charge.

The system also takes social impact into consideration - how failure to treat you is likely to affect your nearest and dearest, how it places a burden on others, how it is likely to mentally disadvantage you or affect the way that others interact with you - which is something that no private insurer is ever going to do. Hence, something like GSO's Sculptra/polylactic acid/New-Fill treatment for facial lipoatrophy, which many would consider a purely 'cosmetic' treatment, is routinely offered free of charge to HIV patients by the National Health Service here in London (and has been since long before it was even approved by the FDA in the US), because it is acknowledged as helping to ease anxiety and correct a distressing, stigmatising and disfiguring side-effect - so the whole point is that rationed doesn't mean second-class. There may not be masses of expensive and privately funded spare capacity floating about in the system, so you may have to wait a month or two for some non-urgent surgical procedures, but correctly run it simply means that the wasteful and pointless procedures are trimmed from the system.

At the end of the day, it is in the best interests of the universal care system to keep you functioning as a healthy and productive, preferably taxpaying, member of society. Not giving you treatments that you need - or treatments that would stop someone else from working because they are having to care for you - is totally counter-productive.

edited for typo

[Inchlingblue]

If NICE recommends a treatment, then it is a treatment that you are legally entitled to. If they don't: you may still be offered it, but can't demand it .. or you can pay for it privately. Quite counter intuitively, they actually tend to approve far more procedures than most private insurers do - in part because the fact that they are there, combined with near monopoly buying power, has created an environment where the drug companies charge the National Health Service substantially reduced rates for their drugs to ensure that they pass the 'value for money' test. Or, in the case of the prohibitively expensive cancer treatment, which only extends life by a matter of months, only charge for the first round of treatment and supply all future rounds of treatments free of further charge.
 
edited for typo

When I was reading the article discussing the drug Sutent I was thinking, if NICE sets a limit at £49,000 (or whatever limit they set) for this drug, the drug company will lower the price accordingly. They have the product and nobody will buy it otherwise so they are stuck with having to sell it at that price. NICE has the upper hand in that negotiation and that's what would happen here in the US if we had a similar system.

from the article:

The decision on Sutent did not, at first glance, appear difficult. NICE had set a general limit of £30,000, or about $49,000, on the cost of extending life for a year. Sutent, when used for advanced kidney cancer, cost more than that, and research suggested it offered only about six months extra life.


The drug companies and others say these changes would stifle innovation but that's not true either. Drug company profits are so extreme that even measures that would cut them somewhat would still leave them very profitable and competitive. And as it is now, they don't research solutions for many of the more rare diseases without government grants anyway. They are not willing to stick their necks out as much as they would like the public to believe. Whatever money is spent on research is because they are pretty sure they will be getting it back and then some.

[MitchMiller]

Inching:

I agree with your fundamental point:  simply insuring a drug because it exists provides a perverse incentive for mediocrity within the drug development industry.  According to published estimates, it can cost 500 - 800M USD to take a drug from the lab to the pharmacy shelf.  If a company has a drug that has little competition, but also limited efficacy, the current system pretty much ensures the drug will get approved and the cost of the drug will be exorbitant... and it will be covered by private insurance (at least in principle). 

Why try harder when you don't have to.  How much of the $$$ spent taking a drug of "limited" efficacy through trials could have been spent to develop a better drug.  Maybe my thinking is too primitive, but it seems rather obvious to me.

[mecch]

Sure hope Obama has the persuasive power to get this Health Care Reform passed.  Even if whatever plan is passed sucks or eventually needs adjustments, there will be no going back...  
If USA can't pay for universal health care, our priorities are all f*cked up. Shame on the insured among the middle class, and the rich, for any indifference or hostility to universal coverage.