Print

---

Following on Prof. White's great response below, an interesting WSJ article
that may be of interest:

http://online.wsj.com/article/SB10001424052970204005504574235751720822322.html

Best regards,
Ali

On Wed, Jul 8, 2009 at 9:41 AM, Joe White <[log in to unmask]> wrote:

>  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 & OUTLOOK<http://online.wsj.com/public/search?article-doc-type=%7BReview+%26+Outlook+%28U.S.%29%7D&HEADER_TEXT=review+%26+outlook+%28u.s.>
> ·         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
>