Thursday, July 9, 2009

Let's Be Like Europe: Giving a whole new meaning to "An Eye for an Eye"

The problem with policy via anecdote is that the inevitable horror stories among any health care system that attempts to serve a population of 300 million people will exercise disproportionate weight over statistical analysis. This is because the math literate speak quantitative and the non-math literate speak qualitative.

So take into account not individual horror stories but systematic restrictions of care when the government becomes involved in dictating what is best practice, it is interesting to look at Great Britain where, as noted in WSJ, if you are going blind due to treatable macular degeneration, the government will only approve treatment for one eye:

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."

I guess it is true what they say: in the country of the blind, the one-eyed man is treated via the public option.

Or how about rejecting the use of Aricept to slow the onset of Alzheimer's as not cost effective or refusing to authorize pap smears for women under twenty-five?

This is all thanks to NICE:

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 does government determination of best practices mean in real terms (aside from blanket restrictions on cutting edge medications)?

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?

Certainly US insurance companies deny care, or make you fight for drugs, or even cancel your coverage in particular instances. But you can bargain with them, threaten them with bad publicity and lawsuits, and you can find people authorized to make exceptions. I've managed to get approval for five more days of in-hospital post-operative stay than BCBS-DE initially wanted to pay, and I've managed to challenge successfully denials of more than 45 physical therapy visits based on reading their own guideline and policies back to them. It can't always be done, but it can often be done with persistence and taking the time to do your homework--which is something you are not going to be able to do with a government body.

Two important notes:

(1) Neither President Obama nor the Washington elites currently debating health care intend to be restricted by the same regulations they are going to put into place. From ABCNews:

Dr. Orrin Devinsky, a neurologist and researcher at the New York University Langone Medical Center, said that elites often propose health care solutions that limit options for the general public, secure in the knowledge that if they or their loves ones get sick they will be able to afford the best care available, even if it's not provided by insurance.

Devinsky asked the president pointedly if he would be willing to promise that he wouldn't seek such extraordinary help for his wife or daughters if they became sick and the public plan he's proposing limited the tests or treatment they can get.

The president refused to make such a pledge, though he allowed that if "it's my family member, if it's my wife, if it's my children, if it's my grandmother I always want them to get the very best care."

So I will accept the idea of a public option when it is good enough for the President and the members of Congress to agree to abide by its treatment limitations.

(2) NICE-style limitations of medications and treatments from that British best-practices model are exactly what the President is talking about. Again, ABCNews:

"There's a whole bunch of care that's being provided that every study, that every bit of evidence that we have indicates may not be making us healthier," he [Obama] said....

End-of-life issues were raised as well; right now it is estimated that nearly 30 percent of Medicare's annual $327 billion budget is spent on patients in their final year of life.

Jane Sturm told the story of her nearly 100-year-old mother, who was originally denied a pacemaker because of her age. She eventually got one, but only after seeking out another doctor.

"Outside the medical criteria," Sturm asked, "is there a consideration that can be given for a certain spirit & and quality of life?"

"I don't think that we can make judgments based on peoples' spirit," Obama said. "That would be a pretty subjective decision to be making. I think we have to have rules that say that we are going to provide good, quality care for all people."

Like only treating macular degeneration in one eye, right, Mr. President? When you're old, who needs depth perception, anyway?

1 comment:

Steve Newton said...

A spam comment by jacksmith--who should be posting as jackass--has been deleted.