I've been invited to speak next week at a conference based on the article by Tito Fojo and Christine Grady ("How Much is Life Worth: Cetuximab, Non-Small Cell Lung Cancer, and the $440 Billion Question") that I wrote a post about three weeks ago. The opportunity has led me to a clearer perspective on the currently undiscussable topic of health care rationing.
Fojo and Grady's central argument - that we in the U.S. should rein in our expenditures on interventions that produce small benefits at enormous cost is so obviously correct that the question to ask is not "are they right?" but rather "what's preventing us from doing what we so obviously need to do?"
I've thought about that question in light of the decision process that NICE (National Institute for Health and Clinical Excellence) uses for the guidance it provides to the National Health Service. NICE has created an elegant approach to setting limits. The logic of NICE's process is simple. (1) The National Health Service has a budget. (2) Every expenditure has an an opportunity cost and should be compared to alternative uses of the funds. (3) For selected new interventions, NICE reviews the evidence about its clinical effectiveness. (4) If the intervention offers clinical benefit NICE asks how much those benefits cost, defined as cost/QALY (Quality Adjusted Life Year). (5) NICE applies a template of social value judgments to the facts that emerge from its analysis. (6) The template includes a threshold range (20-30 thousand pounds/QALY) to guide decisions and a framework for deciding when and how to make exceptions to the threshold. (7) The entire process is conducted in a public manner, with opportunities to see the reasoning behind the conclusions and to raise challenges.
NICE fine tunes its approach over time, but its fundamental logic is sound. The impediment to us in the U.S. doing what Fojo and Grady urge us to do is not the absence of a method for deciding about the worth of marginal benefit. Any country ready to tackle rationing could take NICE's procedures off the shelf, study them, and adapt the process to its own culture and institutions.
The key word here is "ready." And, as Hamlet told us, "readiness is all!"
Experienced psychotherapists teach that the hardest job in treatment is dealing with the resistances to change. Once these impediments have been worked with well enough change almost takes care of itself. That model applies at the level of social process as well.
In my talk I'll take Fojo and Grady's argument as the starting point. They're obviously right. The folks at the conference are predisposed to agree - that's why they invited me. I'm going to suggest that making decisions about marginal benefit is, at heart, not all that difficult. NICE shows us how to do it. The task for all those who agree with Fojo and Grady is not to persuade others to see the same truth, but to chip away at the impediments to seeing the obvious. I'll write more about chipping away impediments in future postings.
(See here for NICE's Social Values Judgments report and here for reports from the Citizens Council.)