This fascinating article appeared in the NYT recently. It discussed the British program called NICE which determines which treatments the National Health Service will cover based on calculations of cost effectiveness. There are many issues brought up that are worth discussion.
First I applaud the efforts of the British government to negotiate prices. While that was not the intended goal of NICE drug companies have increasingly eased prices so that their treatments are covered. This is fantastic. If medicare and medicaid had the power to negotiate prices I'm sure we would save tax payers billions of dollars. Those services represent such a huge share of the market that their power would be profound. And drug prices are so erroneous and exploitive, something has got to be done. Reading this made me wonder why prices aren't tied to efficacy in some way. That kind of price model might in the very least give the drug companies a leg to stand on when they try to defend their fleecing of the dying. I can't imagine this country having the balls to play this kind of hard ball. Even the best solutions put forward this election season for solving the health care crisis are full of consessions to industry. In my optimism I view them as step 1 on a road left.
The ethics of this program are worth discussing as well. If a National budget and health system risks ruin (as I believe ours does) then maximizing cost-benefit for health care may be the only ethical way to insure that citizens are able to rely on a basic standard of care. But deciding that that level of care is going to be less than the highest that our technologies and skills are capable of is a hard pill to swallow for anyone. I don't know if the British ever claim to have the best health care in the world but I know the US certainly does. Despite the fact that we don't. We are capable of delivering great care to the relatively few rich and well insured. But our health outcomes as a nation are embarrassingly behind the rest of the world. Pragmatically, it is imparative that we accept that so far we have failed; that 'slowing progress' which industry threatens may be a necessary concession to save the masses and wallets of all.
Patients in Britain who are on the losing end of NICE, like the patient with kidney cancer, might be best served in the future by a two tier system. This is the system that I ultimately believe the US will be forced to adopt, as it is the only one that I can imaging being both financially tenable and still leaves a place for our precious free market. In this system you have universal health care for everyone that assures an 'adequate' level of health care, and you have a private optional insurance system that people can buy to pick up where universal care leaves off. Because a standard level of care is already maintained this could really work on an old school insurance style model, and possibly serve consumers much better. Fewer people would make claims and things like doctor choice and elective and heroic procedures could more easily be covered. As a future physician I cannot see this as an ethically perfect solution. I believe a physicians ethical obligation is always to provide the highest standard of care they are able to each of their patients. The British NICE deserves a lot of credit for its dedication to egalitarianism.
"After consulting a citizens group, the institute decided that the nation should spend the same amount saving or improving the life of a 75-year-old smoker as it would a 5-year-old." When it comes to life I am definitely a quality over quantity kind of girl. It really bothers me that improving a life is subject to the same cost effective analysis that extending a life is. If a drug fits their criteria of extending a life for 6 months but has horrible and debilitating side effects this too should be considered in the financial analysis. And if quality of life is improved, as for the MS patient mentioned in the article, I find it extremely unsettling to deny the treatment. As policy this gets dicey. Ideally this is the sort of decision a patient should be allowed to weigh in on.
The reality of our situation, in the midst of a war and a financial crisis, is that we are going to be forced as a society to make some tough decisions. Should smokers pay more for health care? Should fat people? But all of it involves making a decision that I'm still not sure we as a nation have made. Barack Obama made me swoon in the second debate when he said, simply and directly, that he thought "[health care] should be a right." Making and embracing this idea emphatically requires that we come up with a quality level of care that is freely available to everyone. Realistically we must also realize it can't be perfect.
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4 comments:
You did write a post didn't you! good for you.
No, Brits don't really ever say much about being or having the best of anything. And certainly not health care; there's a lot of complaint in the media, though the unrepresentative slice of the population I talk to is appreciative of the NHS. Generally they seem to be excellent at emergency one-off stuff and worse at chronic stuff where you have to keep track of paperwork and get back to people (there's a long story about C's non-hernia here).
The two tier system that you talk about is a major point of discussion. Basically people here seem to think it's unfair and unegalitarian, and the current rules are such that once you go private for anything you lose your NHS coverage completely. ...
Nope wait did some research and found out that that changed just a month ago. So now private 'top-ups' are allowed: http://news.bbc.co.uk/1/hi/health/7658539.stm
I'm still not sure what my position on this is --- and because I'm happily healthy, it's of necessity a fairly theoretical position. I don't like the idea of life or death being determined by someone's ability to pay. (Then again, life expectancy is linked to ability to wealth and ability to afford healthy food etc etc in all kinds of ways, so it's a general problem. In the cancer patient situation it's rather more black and white, forcing the issue out from under the carpet.) So theoretically I'm against top-up payments. On the other hand, some people just do have the money, and if they want to trade it in for the possibility of six months of life, disallowing that seems incredibly cruel too.
I'm worried about the slippery slope though, where the NHS becomes eroded and more and more treatments end up being private only. One can only hope that the NHS and truly free and universal health care is enshrined enough in public opinion to prevent that. I suspect it is (and the incoming economic disaster will only underline its importance; there's your silver lining).
However, exactly that *will* be a severe problem for such a two-tier system in the US, especially with the added pressure of crazy pharma lobbyists. Where is the line between 'adequate' and 'elective'? How hard will it be to convince a politician to add a rider removing yet another little-known disease from universal care? And how to prevent that, while still giving the system the necessary flexibility?
Another issue is the problem of preventative care (something the NHS isn't brilliant on --- e.g. pap smears at our age are only every three years, not every year as in the States; on the other hand, presumably they've run their stats? It goes up to yearly for women in their forties or so.). A system that focuses on 'adequate' health care will be tempted to cut down on everything that isn't immediately related to fixing current crises, even if it helps in the long run (since as a governmental program it will be under budget pressures from people who don't give a rat's ass about the long run, i.e. politicians). But again you can argue that lots of preventative stuff (eat right, exercise right, etc) is already skewed towards the wealthy, so it's not changing much, inasmuch as our general capitalistic system of life is concerned.
So, once again the general conclusion is Down with Capitalism and Up with Idunnowhat. Zapatista collectivism? Super complex and specialised practices such as health care (above GP) present a real problem for localised anarchical systems, which are what I would sympathise towards. But this is now getting tremendously off-topic. And I do believe there's more value in fixing the concrete and the present, rather than fiddling around with idealised futures/alternatives.
Its interesting that you think a government program is necessarily going to be bad at preventative care. I see how it might be an easy thing to cut in a budget crunch but I think that the system we have in the US is actually much worse on preventative care. (By the way, paps are now every 3 years here too.) The average amount of time a person in the US stays with a single HMO is between three and five years. This means there is extremely little incentive to cover preventative care. If you have a single payer, or some other assurance of a long term relationship, your short term cuts are going to come back to get you. Under the current system it's somebody else's problem. You're right though, given that the national deficit no longer fits on the sign in New York it's clear our leaders don't mind bankrupting the future. The generation that are children today is likely to be the first generation in history with a shorter life expectancy and less healthy lives than their parents.
Right. I didn't say (and didn't mean to imply) that the US system is any *better* than a nationalised system at preventative care - far from that, and you know the arguments better than I do. If those are the two options, the nationalised system is probably going to be better, because, as you say, the nationalised system is going to get stuck with the long term costs. However, if you have a two-tier system, the nationalised system then has the option of externalising those costs by handing them over to the 'elective' system (maybe depending on what they are exactly). So again the decision over 'adequate' vs 'elective' has to be made extremely carefully, apolitically and alobbyistically.
Then there's also an interesting debate one could have about preventative care/early warning vs quality of life. There's something appealing about the idea of *not* knowing you have a disease and just falling over one day, vs a million trips to the hospital. (Ok, that's a straw man argument since most cases will be neither one or the other.) I think our culture is over-medicalised (different from over-medicated): people eat to get macronutrients, exercise to keep blood pressure down. Or rather probably I should say food gets sold as macro-nutrients, not deliciousness; exercise gets sold as a medical routine, rather than a nice walk in the park. Michael Pollan makes this argument better than I do. Also I'm yet again turning this discussion into a Smash The System rant and so I will stop now and try and go take a walk in said park.
I totally agree.
For more shocking proof of overmedicalization, spend a day in med school. ;) Did you know that hospitals now have explicit policies in place mandating that if a mother asks to see her new born baby that she be allowed to? I could go on an on about the over medicalization of child birth specifically but to me that factoid just took the cake. How gross is it that we got so far into our own industrial medical complex world that giving a mom her baby became something that people had to fight for?
And also I second everything michael pollan ever said and think he should be appointed "food czar" or some such thing as long as it is all powerful.
Your two tier system argument is also valid but I think it may be a necessary evil of health care reform. In this country especially we are looking for the least evil system, not the best system. But again, I think recognizing that is a big obstacle to major policy reform.
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