Wednesday, December 3, 2008

NICE is teaching the world about health care limits

Today's New York Times has a fascinating article about the firestorm triggered by NICE's decision not to cover Sutent, an cancer drug that may extend life of kidney cancer patients for 6 months, but at a cost of $54,000.

The article shows that NICE is the world's leading teacher about the ethical imperative for societies to set health care limits. I've quoted some excerpts from the article (in italics) followed by my comments.
"'Everybody should be allowed to have as much life as they can,' Joy Hardy [wife of Michael Hardy, who has kidney cancer] said...'It's hard to know that there is something out there that could help but they're saying you can't have it because of cost...What price is life?'"
Mrs. Hardy is profoundly right - deciding not to cover Sutent is a tragic choice. In terms of Albert Schweitzer's concept of reverence for life, the answer to the question "what price is life?" is - "it's priceless." But in economic terms, it's not.

Some years ago, Lester Thurow, then Dean of MIT's Sloan School of Management, suggested that we think about this kind of decision in terms of how much human labor the cost represents. $54,000 is a bit more than the average annual wage in the U.K. Asking "is it right to require John Doe to turn over his entire year's earnings to give Mr. Hardy a chance to live 6 more months?" feels significantly different than asking "should we allow a bureaucrat to sacrifice Mr. Hardy for $54,000?" Money isn't paper - it's ultimately human labor. We should have reverence for John Doe's life as well as Mr. Hardy's.
"Even in the United States, rising costs have led some in Congress to propose an institute that would compare the effectiveness of new medical technologies, although the proposals so far would not allow for price considerations...the idea of using price to determine which drugs or devices Medicare or Medicaid provides has provoked fierce protests."
The idea that we would forbid our government to consider cost - in other words, say that even if 100 or 1,000 John Does had to sacrifice their entire annual income they would have to do so to provide a chance for 6 more months of life - is so preposterous that it calls to mind Schopenhauer's famous comment about a philosophical assertion he found equally preposterous: "As a serious conviction it could be found only in a madhouse; as such it would then need not so much a refutation as a cure."

With regard to our public discourse about health policy, the U.S. is indeed a madhouse!
Robert Goldberg, vice president of the Center for Medicine in the Public Interest, an advocacy group financed by drug makers, likened Dr. Rawlins (director of NICE) and his institute to terrorists..."
This kind of Karl Rove take-no-prisoners rhetoric from a well paid PhRMA shill shows what NICE and its leadership is up against. I hope Michael Rawlins has a thick skin and a good sense of humor.
"Dr. Rawlins said he was frustrated that his institute had been censured instead of the drug company executives who set sky-high prices."
He's right to be frustrated!

Anyone who has brought up children knows how difficult it is to teach about limits and sharing. It takes patience, firmness, love and understanding the cost to the child of not learning. Children don't thank us. Like the hypocritically named "Center for Medicine in the Public Interest" they call us the equivalent of terrorists.

NICE is the kind of teacher the developed world - especially the U.S. - needs. Let's hope Michael Rawlins and his colleagues can keep up the good work!


Anonymous said...

I just happened across your blog and am enjoying your perspective.

Debating the high cost, high complexity, high tech rationing of care is necessary, but as we allow (and sometimes enforce) millions of people to deny themselves primary and preventive care, isn't this a bit of the cart before the horse?

Couldn't we figure out some scheme on a national basis by which to have meaningful debates about healthcare rationing and apportioning which then drive public policy and allow for case exceptions. It's the demand for a solid boundary, inflexible yes or no answer to funding and allocating resources in these kinds of situations that leave me uneasy and queasy. *g*

Sort of like addressing Maslow from the top down instead of meeting basic needs and working up toward meeting more complex and qualitative needs.

Jim Sabin said...

Hi Annie -

Welcome to the blog and thank you for your very thoughtful comment.

I agree that the U.S. health care "system" puts the cart of high tech and specialty care before the horse of primary care and prevention. To rectify the situation the U.S. will have to reallocate funds from the high tech/specialty sector to primary care and prevention.

I also agree that a yes it's covered/no it isn't approach to health care is not ideal. Genomics is likely to help here, as in the finding that a particular gene form predicts whether patients with colon cancer may be helped by Eerbitux.

Except when John Kitzhaber was Senate President and then Governor of Oregon, the U.S. has not had "meaningful debates about healthcare rationing and apportioning." The deepening recession may knock some sense into our national head, but "meaningful" rather than "academic" policy debate will require a kind of political leadersip we have seen too little of.

I hope you'll prod and enlighten the blog with more comments in the future!



Anonymous said...

Facts that are believed to exist regarding the present U.S. Health Care System-
This may be why about 80 percent of U.S. citizens want our health care system overhauled:
The U.S. is ranked number 42 related to life expectancy and infant mortality, which is rather low.
U.S. is ranked number one in the world for spending the most for health care- as well as being number one for those with chronic diseases. About 125 million people have such diseases. This is about 70 percent of the Medicare budget that is spent treating these terrible illnesses. Health Care cost presently is over 2 trillion dollars of our gross domestic product. One third of that amount is nothing more than administrative toxic waste that does not involve the restoration of the health of others. This illustrates how absurd the U.S. Health Care System is presently. Nearly 7000 dollars is spent on every citizen for health care every year, and that, too, is more than anyone else in the world.
We have around 50 million citizens without any health insurance, which causes about 20 thousand deaths per year. This includes millions of children without health care, which is added to the planned or implemented cuts in the government SCHIP program for children that covers about 7 million kids.
Our children
Nearly half of the states in the U.S. are planning on or have made cuts to Medicaid, which covers about 60 million people, and those on Medicaid are in need of this coverage largely due to unemployment. With these Medicaid cuts, over a million people will lose their health care coverage and benefits.
About 70 percent of citizens have some form of health insurance, and the premiums for their insurance have increased nearly 90 percent in the past 8 years. About 45 percent of health care is provided by our government- which is predicted to experience a severe financial crisis in the near future with some government health care programs, it has been reported. Most doctors want a single payer health care system, which would save about 400 billion dollars a year- about 20 percent less than what we are paying now. The American College of Physicians, second in size only to the American Medical Association, supports a single payer health care system. The AMA, historically opposed to a single payer health care system, has close to half of its members in favor of this system. Less than a third of all physicians are members of the AMA.
Our health care we offer citizens is sort of a hybrid of a national and private health care system that has obviously mutated to a degree that is incapable of being fully functional due to perhaps copious amounts and levels of individual and legal entities.
Half of all patients do not receive proper treatment to restore their health, it has been stated. Medical errors desperately need to be reduced as well, it has been reported. It is estimated that we need about 60 thousand more primary care physicians to satisfy the medical needs of the public health in the United States. And we have some greedy corporations that take advantage of our health care system. Over a billion dollars was recovered for medicare and Medicaid fraud last year through settlements paid to the department of Justice because some organizations ripped off taxpayers. These are the taxpayers in the U.S. who have a fragmented health care system with substantial components and different levels of government- composed of several legal entities and individuals, which has resulted in medical anarchy.
Thanks to various corporations infecting our Health Care System in the United States, the following variables sum up the U.S. Health Care System, which is why the United States National Health Insurance Act (H.R. 676) is the best solution to meet our health care needs as citizens. We would finally have, as with most other countries, a Universal Health Care system that will allow free choice of doctors and hospitals. It should be and likely will be funded by a combination of payroll taxes and general tax revenue:
Access- citizens do not have the right or ability to make use of this system as we should.
Efficiency- this system strives on creating much waste and expense as it possibly can.
Quality- the standard of excellence we deserve as citizens with our health care is missing in action.
Sustainability- We as citizens cannot continue to keep our health care system in existence , or tolerate it as it exists today any longer,
Dan Abshear

Jim Sabin said...

Hello Dan -

Thank you for this very full comment. You are a cornucopia of important facts about the health systemA. Let's hope that under the incoming administration the U.S. will see significant changes in our broken system, in which we pay so much for such poor overall results.