Obamacare

Comparing Our Way to Rationed Health Care

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The federal stimulus package included $1.1 billion for comparative effectiveness research of medical treatments. Of course, no one wants to use less rather than more effective treatments, but such research can lead to one-size-fits-all medicine.

comparative effectiveness

This is particularly ironic as the age of personalized medicine in which treatment regimens will be tailored to each person's genetic makeup and specific disease characteristics is dawning. Representatives of women's and minority groups have also expressed concern that comparative effectiveness research will ignore differences in medical responses to various treatments that arise from differences in gender and ethnicity. A letter from the Congressional Black Caucus warns:

We are concerned that comparative effectiveness research will be based on broad population averages that ignore the differences between patients.

Supporters of the new federal comparative effectiveness research program claim that such research will look only at comparative clinical effectiveness, not at cost-effectiveness.

Cost-effectiveness means deciding whether or not a treatment is "worth" the amount of money spent on it from the point of view of the payor, not the point of view of the patient or her physician. This is how Britain's National Institute for Health and Clinical Excellence (NICE) works. NICE regularly denies British patients access to drugs that would likely prolong their lives. For example, today the Daily Mail reports

Thousands of patients with terminal cancer were dealt a blow last night after a decision was made to deny them life prolonging drugs.

The Government's rationing body said two drugs for advanced breast cancer and a rare form of stomach cancer were too expensive for the NHS (National Health Service). …

One drug, Lapatinib, can halve the speed of growth of breast cancer in one in five women with an aggressive form of the disease.

Dr Gillian Leng, Nice deputy chief executive, said 'The committee concluded that Lapatinib is not a cost-effective use of NHS resources when compared with current treatment.'

Up to 1,500 stomach cancer patients also face a ban on Sutent – the only drug that can extend their lives.

The report accompanying the stimulus bill in the House of Representatives indiscreetly observed:

By knowing what works best and presenting this information more broadly to patients and healthcare professionals, those items, procedures, and interventions that are most effective to prevent, control, and treat health conditions will be utilized, while those that are found to be less effective and in some cases, more expensive, will no longer be prescribed.

This language suggesting that comparative effectiveness research would be used to limit access to treatments under Medicare and Medicaid was later dropped when the Senate passed the bill. Nonetheless, few doubt that clinical effectiveness results can very easily transmogrify into cost-effectiveness arguments. But why not save taxpayers money by having the government refuse to pay for ineffective treatments? Because it won't work that way.

A recent Congressional Budget Office (CBO) study found that comparative effectiveness research is not likely to save the federal medical programs—Medicaid and Medicare—much mony anyway. In its study, the CBO calculated that comparative effectiveness research outlays would amount to $2.4 billion over 10 years. Then the CBO estimated that Medicare and Medicaid would save a total of $1.3 billion through reduced expenditures as a result of the comparative clinical effectiveness research. Spending money on comparative effectiveness research would cost $1.1 billion more than it saves the federal government over the next ten years. These amounts are tiny in comparison to the $2.3 trillion that Americans spent on health care in 2007.

The CBO concludes,

Generating additional information comparing treatments would tend to reduce federal health spending somewhat in the near term—but the effect may not be large enough to offset the full costs of conducting the research over the same period of time.

In other words, determining comparative clinical effectiveness—determining that certain treatments are better others—simply will not result in big health care savings.

Comparative effectiveness research could also slow the development of new treatments. The Boston Globe reports:

The most cost-effective drugs may not work for everyone, though, said Joff Masukawa, senior director of government relations and public policy for Shire Ltd., which makes specialty biopharmaceuticals. Assigning a cost-effectiveness grade to a drug or therapy could eventually discourage drug companies from pursuing innovative drugs that treat rare diseases or help relatively few patients, he said.

In addition, clinical effectiveness can be taken into account by private insurers as the Globe notes:

Karen Ignagni, president of America's Health Insurance Plans, an association of health insurers, said one way insurers could take the results of the research into account may be to offer a tiered system that requires patients to pay more for treatments that are seen as less cost-effective.

So instead of bureaucrats deciding for everyone what will be available, the balancing of costs and benefits can be made explicit in the insurance policies that people or their employers purchase. 

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  1. Mr. Bailey missed a big health care story this week it looks like.

    Anywho, in a rousing victory for states rights and decentralized law, Wyeth (check your rolodex under “W”) and the Bush Administration lost at the Supreme Court this week in favor of Vermont state tort law and one-armed musicians.

  2. We will be seen as paranoid conspiracy theorists for thinking this will lead to socialized medicine up until the day this leads to socialized medicine (for our own good, or course).

  3. Supporters of the new federal comparative effectiveness research program claim that such research will look only at comparative clinical effectiveness, not at cost-effectiveness.

    Shockingly naive, or just criminally stupid?

  4. jsh,

    Dude you are seriously wrecking the economy! Only time for HOPE and CHANGE remember? Not your pessimism!

  5. We will be seen as paranoid conspiracy theorists for thinking this will lead to socialized medicine up until the day this leads to socialized medicine (for our own good, or course).

    It is for the good of the whole, not the individual.

  6. I’m beginning to think that the only thing not included in the stimulus package was a million dollar check to me.

  7. In modern health care systems, these decisions will usually be made be bureaucrats public or private. The difference is in public systems there is usually an open process where these choices are made about whether to fund certain treatments or not. In a private system these decisions are made with an eye towards the company’s bottom line, leaving the patient with no option but to sue. Not surprisingly, many patients don’t have the financial means or stamina for this, not to mention dying before the case comes to court.

  8. In order to bring costs down, what we need to do is be more like the Europeans and be better able to accept a hopeless diagnosis. We need to think of what is best for society and not just our selfish needs.

    1. obviously if you’re serious….you have never had anyone you love dearly that you have watched be in agony from the pain that is cancer…. hopefully you will never have to endure it. But for those of us who have, we hope and pray that there will be help for our loved ones.

  9. In order to bring costs down, what we need to do is be more like the Europeans and be better able to accept a hopeless diagnosis.

    Agreed, also, we need to accept euthanasia as a means of saving costs for patients in chronic pain.

  10. “In order to bring costs down, what we need to do is be more like the Europeans and be better able to accept a hopeless diagnosis. We need to think of what is best for society and not just our selfish needs.”

    Please tell me you were being ironic. If you weren’t, why don’t you just be honest and say that sick people need to quit being selfish and just die so they are not a burden to the healthy?

    Leftists come for the sick and the different first. They kill them and dehumanize them first. Then they dehumanize everyone and kill anyone who poses a problem for the good of the society. Sick fuckers.

  11. Can we just strip the liberals for donor organs if our health is their top consideration?

  12. The idea is that once it’s “settled” that a group of govt “experts” knows best what medical treatment you should have, then of course they should be given the power to make that decision for you.

  13. we need to accept euthanasia

    YES!


  14. Please tell me you were being ironic. If you weren’t, why don’t you just be honest and say that sick people need to quit being selfish and just die so they are not a burden to the healthy?

    Yes, of course. I was just sarcastically showing the end result of this thinking.

  15. What are the chances that treatments that are deemd too expensive will in fact be denied to say members of Congress or important political donors? Anyone?

  16. Well the people can still by the meds them self. In any system you have to advocate for yourself. Compare this to what HMO or PPO, etc will or will not cover–sure you can take it but they will pay nothing. So what is the difference? While I’m far from advocating gov’t health care how is a private system different in this? (you can chose providers and pay more is about all). Now show a chart with Blue Cross/an average PPO provider and France/Britain and what is and isn’t covered / prices, etc and you have something interesting. (I have no idea what it’d show but it’d have some value to the debate).

  17. Good Steven. I thought you were. Sorry to assume the worst.

  18. David–What’s your last name? I got 2 of them and I think one of them is yours.

  19. I am a medical oncologist in the United States. 47216 is the number of my certificate from the board certifying me in medical oncology.
    The idea that an insurance company driven program would work better than some government bureaucrat is great. I need a laugh to start the day seeing cancer patients who can’t afford lapatinib under our current system.
    The quote from the guy working for the pharma company was a bonus laugh.
    Keep up the good work.

  20. Leftists come for the sick and the different first. They kill them and dehumanize them first.

    First we “help” the smokers and the fat ones.

  21. From personal experiences (unfortunately), I’ve found that private hospitals’ patient advocates and oncology social workers can be very effective in going to bat for terminally ill patients and their treatment.

    Don’t think they’d have much clout in a government-run program. The patient would be dead before the paperwork for an appeal got looked at.

  22. “The idea that an insurance company driven program would work better than some government bureaucrat is great. I need a laugh to start the day seeing cancer patients who can’t afford lapatinib under our current system.”

    Tell us more. How many patients do you have that can’t afford the treatment and are not getting it? Would getting it them in your professional opinion any good? Is it your professional opinion that patients in your care are being denied effective treatments by insurance companies? If so, what treatments? How many patients?

    I would be very curious to hear what you have to say beyond snark. If you really do have knowledge of how the system works. Please tell us. Also, what if anything is your experience with the UK? If you have any, do you feel that their patients get as good or better care than your patients? If you don’t have knowledge of the UK, what is the basis of your opinion for saying the government would do as well as the current system?

  23. I don’t understand this irrational I’m getting mine at any cost right up until God calls me home.

    You CANNOT have a rational discussion about health care until we admit that everybody can’t afford the latest treatments and medicine for any condition all the time, particularly for prolonging terminal diagnoses.

    If you can pay for it great, but it just ain’t gonna work out for everyone or even the majority. Private or public funding doesn’t matter.

    We’re all gonna die, get over it.

    If I make it to average life expectancy, every day after that is gravy. If I make it, or even if I don’t, at no point do I expect the gov’t, my family, my insurer, or anybody else to spend hundreds of thousands on treatment I can’t afford to get me a year or three after I get the crappy cancer diagnosis.

    Jack Kevorkian was ahead of his time. If you don’t get that, you’re demographically clueless.

  24. Somebody has to make cost-effectiveness decisions, and it seems a majority of Americans don’t want to do it. So they let the HMO do it, then they can complain about it. If Obama has his way, the Feds will do it, and people will still complain about it.

    It’s a lot easier on the conscience to feel that the HMO killed Grandma because they were too greedy, or the Feds killed Grandma because they were too incompetent and bureaucratic, than to admit you let Grandma die because it wasn’t worth blowing your kids college fund to keep her alive another 2 months.

  25. “It’s a lot easier on the conscience to feel that the HMO killed Grandma because they were too greedy, or the Feds killed Grandma because they were too incompetent and bureaucratic, than to admit you let Grandma die because it wasn’t worth blowing your kids college fund to keep her alive another 2 months.”

    That is a horseshit strawman. People turn down treatment while terminally ill all the time. What makes people angry is not the decision to end treatment. People do not want to give their loved ones or themselves treatments that won’t do any good. You have to remember these treatments suck. There are huge side effects. People don’t want to needlessly suffer for a few days of life.

    But what people want to do is have a say in the treatment they get. They want to decide when enough is enough, not the government or a healthcare administrator. That is what the debate is about.

  26. But what people want to do is have a say in the treatment they get. They want to decide when enough is enough, not the government or a healthcare administrator. That is what the debate is about.

    Red BS flag.

    $1M for me, $50k for you. $5M for my child, $500k for yours.

    Dogzilla has is exactly right.

  27. Jack Kevorkian was ahead of his time.

    YES! YES! YES!

  28. “Dogzilla has is exactly right.”

    No he is giving a bullshit strawman. People chose to end treatment of the terminally ill all the time.

  29. John:

    I’m a guy on the front-line and have not made a systemic count of these issues; however, this is the internet, and anedote=data.
    This morning I have seen a patient with lung cancer who is approved for erlotinib but can’t afford the co-pay. He has insurance. Because he has insurance, he does not qualify for the forms of assisstance that are out there. I saw a woman with Waldenstrom’s who will not be getting bortezomib because it is “off-label.” I am scheduled to see a new patient with a glioma; I’ll probably be able to get her on Avastin, but it will be a process.
    My only experience with the UK is as a tourist. My sense is that there is a greater feeling of community (or resignation) leading to greater acceptance of the way things are.
    Like I said, I am just one frontline soldier here not a general.

  30. You say BS strawman, I don’t.

    But let’s get to the issue – who gets to determine cost-effectiveness when you can’t pay?

  31. 47216: Thanks very much for the ground-level insight. And yet, some of your insured patients do have access to the drugs you describe, whereas in the NHS, those with diseases whose treatments are ruled cost-ineffective won’t. And aren’t most of newer treatments available largely because of robust private pharmaceutical research?

    And then there is the very odd case last year in which the NHS stopped paying for a woman’s colon cancer treatments after she paid privately for the anti-cancer drugs that had been denied her under NHS on the grounds that they were not cost-effective.

  32. Aren’t we missing the elephant here? This research is a total waste of money, since comparative effectiveness has already been established by the relevant trials and subsequent statistical monitoring. The notion that doctors don’t know what treatments are effective without the government telling them is insulting.

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