Joe,
Thanks for this thoughtful response--
Shirley
----- Original Message -----
From: Joe White <[log in to unmask]>
To: [log in to unmask]
Sent: Wed, 8 Jul 2009 09:41:43 -0400 (EDT)
Subject: Re: WSJ attacks NICE again
NICE certainly has been ASSOCIATED with massive, mostly planned, increases
in expenditures. So the WSJ piece is remarkably misinformed and/or
dishonest. Probably both.
Of course, the WSJ piece is just echoing some highly distinguished American
reformers who also have claimed, falsely, that NICE is a reason the U.K.
system is less expensive. This is a case of the promotionalism for
"evidence based medicine," etc coming back to haunt reformers. So the fact
that both sides' claims about NICE are false is only part of the story.
What American reformers ought to realize is that "evidence-based medicine"
led by a government body politically equals the government interfering with
your physician's judgment about what care you should have, which then equals
government rationing of care. The issue then reduces to whom do you trust,
the government or your doctor. And this is a dead-certain loser for health
care reformers in the U.S..
HSR types can say anything they want about it's really not the government,
the guidelines will be developed by clinicians, doctors make all sorts of
unjustified choices, etc. It still comes down to a trust competition in
which the personal physician has a huge advantage BECAUSE PEOPLE HAVE TO
TRUST HER ANYWAY. You're already letting your doctor diagnose you, invade
your body in various ways, see you in a vulnerable state - and so people
have to invest some trust in their docs.
Which doesn't mean people want docs to make all the money in the world.
Price regulation is fairly popular. But if it's your doctor managing your
care, or the government managing care, or the insurance company managing
your care, the doc wins.
And the conservatives know that, even if editorial writers and most of the
membership of Academy Health do not.
Joe White
From: Anglo-American Health Policy Network [mailto:[log in to unmask]] On
Behalf Of Birch, Stephen
Sent: Wednesday, July 08, 2009 9:07 AM
To: [log in to unmask]
Subject: Re: WSJ attacks NICE again
Which bit do you object to - surely not the arbitrary nature of the
threshold - even Michael Rawlings has admitted this was simply made up by
some health economists. I find the notion that it has held down costs
interesting - my understanding is that NICE has led to massive unplanned
increases in expenditures - not bad for something charged with the NHS goal
of maximising health gain from available resources (as opposed to maximising
health care resources for whatever gain might be produced).
OK, the blue touch paper has been lit - I await the big bang!
Steve Birch
From: Anglo-American Health Policy Network [mailto:[log in to unmask]] On
Behalf Of Jost, Timothy
Sent: July-08-09 8:45 AM
To: [log in to unmask]
Subject: WSJ attacks NICE again
The Wall Street Journal has another editorial this morning attacking one of
its favorite bogeymen, NICE. If we aren't careful, apparently, we will soon
all be dying in the streets like people in the UK. I would be grateful if
someone who actually knows something about NICE could respond, at least with
a letter, perhaps with an op ed.
Tim
*
. REVIEW
<http://online.wsj.com/public/search?article-doc-type=%7BReview+%26+Outlook+
%28U.S.%29%7D&HEADER_TEXT=review+%26+outlook+%28u.s.> & OUTLOOK
. JULY 8, 2009
Of NICE and Men
.
Speaking to the American Medical Association last month, President Obama
waxed enthusiastic about countries that "spend less" than the U.S. on health
care. He's right that many countries do, but what he doesn't want to explain
is how they ration care to do it.
Take the United Kingdom, which is often praised for spending as little as
half as much per capita on health care as the U.S. Credit for this cost
containment goes in large part to the National Institute for Health and
Clinical Excellence, or NICE. Americans should understand how NICE works
because under ObamaCare it will eventually be coming to a hospital near you.
* * *
The British officials who established NICE in the late 1990s pitched it as a
body that would ensure that the government-run National Health System used
"best practices" in medicine. As the Guardian reported in 1998: "Health
ministers are setting up [NICE], designed to ensure that every treatment,
operation, or medicine used is the proven best. It will root out
under-performing doctors and useless treatments, spreading best practices
everywhere."
What NICE has become in practice is a rationing board. As health costs have
exploded in Britain as in most developed countries, NICE has become the
heavy that reduces spending by limiting the treatments that 61 million
citizens are allowed to receive through the NHS. For example:
In March, NICE ruled against the use of two drugs, Lapatinib and Sutent,
that prolong the life of those with certain forms of breast and stomach
cancer. This followed on a 2008 ruling against drugs -- including Sutent,
which costs about $50,000 -- that would help terminally ill kidney-cancer
patients. After last year's ruling, Peter Littlejohns, NICE's clinical and
public health director, noted that "there is a limited pot of money," that
the drugs were of "marginal benefit at quite often an extreme cost," and the
money might be better spent elsewhere.
In 2007, the board restricted access to two drugs for macular degeneration,
a cause of blindness. The drug Macugen was blocked outright. The other,
Lucentis, was limited to a particular category of individuals with the
disease, restricting it to about one in five sufferers. Even then, the drug
was only approved for use in one eye, meaning those lucky enough to get it
would still go blind in the other. As Andrew Dillon, the chief executive of
NICE, explained at the time: "When treatments are very expensive, we have to
use them where they give the most benefit to patients."
NICE has limited the use of Alzheimer's drugs, including Aricept, for
patients in the early stages of the disease. Doctors in the U.K. argued
vociferously that the most effective way to slow the progress of the disease
is to give drugs at the first sign of dementia. NICE ruled the drugs were
not "cost effective" in early stages.
Other NICE rulings include the rejection of Kineret, a drug for rheumatoid
arthritis; Avonex, which reduces the relapse rate in patients with multiple
sclerosis; and lenalidomide, which fights multiple myeloma. Private U.S.
insurers often cover all, or at least portions, of the cost of many of these
NICE-denied drugs.
NICE has also produced guidance that restrains certain surgical operations
and treatments. NICE has restrictions on fertility treatments, as well as on
procedures for back pain, including surgeries and steroid injections. The
U.K. has recently been absorbed by the cases of several young women who
developed cervical cancer after being denied pap smears by a related health
authority, the Cervical Screening Programme, which in order to reduce
government health-care spending has refused the screens to women under age
25.
We could go on. NICE is the target of frequent protests and lawsuits, and at
times under political pressure has reversed or watered-down its rulings. But
it has by now established the principle that the only way to control
health-care costs is for this panel of medical high priests to dictate
limits on certain kinds of care to certain classes of patients.
The NICE board even has a mathematical formula for doing so, based on a
"quality adjusted life year." While the guidelines are complex, NICE
currently holds that, except in unusual cases, Britain cannot afford to
spend more than about $22,000 to extend a life by six months. Why $22,000?
It seems to be arbitrary, calculated mainly based on how much the government
wants to spend on health care. That figure has remained fairly constant
since NICE was established and doesn't adjust for either overall or medical
inflation.
Proponents argue that such cost-benefit analysis has to figure into
health-care decisions, and that any medical system rations care in some way.
And it is true that U.S. private insurers also deny reimbursement for some
kinds of care. The core issue is whether those decisions are going to be
dictated by the brute force of politics (NICE) or by prices (a private
insurance system).
The last six months of life are a particularly difficult moral issue because
that is when most health-care spending occurs. But who would you rather have
making decisions about whether a treatment is worth the price -- the
combination of you, your doctor and a private insurer, or a government board
that cuts everyone off at $22,000?
One virtue of a private system is that competition allows choice and
experimentation. To take an example from one of our recent editorials,
Medicare today refuses to reimburse for the new, less invasive preventive
treatment known as a virtual colonoscopy, but such private insurers as Cigna
and United Healthcare do. As clinical evidence accumulates on the virtual
colonoscopy, doctors and insurers will be able to adjust their practices
accordingly. NICE merely issues orders, and patients have little recourse.
This has medical consequences. The Concord study published in 2008 showed
that cancer survival rates in Britain are among the worst in Europe.
Five-year survival rates among U.S. cancer patients are also significantly
higher than in Europe: 84% vs. 73% for breast cancer, 92% vs. 57% for
prostate cancer. While there is more than one reason for this difference,
surely one is medical innovation and the greater U.S. willingness to
reimburse for it.
* * *
The NICE precedent also undercuts the Obama Administration's argument that
vast health savings can be gleaned simply by automating health records or
squeezing out "waste." Britain has tried all of that but ultimately has
concluded that it can only rein in costs by limiting care. The logic of a
health-care system dominated by government is that it always ends up with
some version of a NICE board that makes these life-or-death treatment
decisions. The Administration's new Council for Comparative Effectiveness
Research currently lacks the authority of NICE. But over time, if the Obama
plan passes and taxpayer costs inevitably soar, it could quickly gain it.
Mr. Obama and Democrats claim they can expand subsidies for tens of millions
of Americans, while saving money and improving the quality of care. It can't
possibly be done. The inevitable result of their plan will be some version
of a NICE board that will tell millions of Americans that they are too
young, or too old, or too sick to be worth paying to care for.
Printed in The Wall Street Journal, page A13
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