Map of life expectancy at birth from Global Education Project.

Wednesday, January 21, 2015

It can't happen here . . .

. . . but it should. I'm talking about evaluating medical interventions in terms of their costs as well as their benefits. And I do mean monetary costs.

In the UK, the Death Panel is called the National Institute for Health and Care Excellence (NICE -- in the acronym they omit the H). This blog post by Austin Frakt explains how they do it. He doesn't really explain the Incremental Cost Effectiveness Ratio, so I will tell you that in simple terms it's the cost per Quality Adjusted Life Year of a treatment. Here's the definition of a QALY:

A quality-adjusted life-year (QALY) takes into account both the quantity and quality of life generated by health care interventions. It is the arithmetic product of life expectancy and a measure of the quality of the remaining life-years.

The quality adjustment part is probably the most controversial, and I agree that it is somewhat dubious.  However, you do have to think about it in some way because some conditions of life, let's face it, just aren't worth very much. Uh oh! Culture of Death!

Alright, let's posit that human life is infinitely precious and you can't put a price on it. Okay, look right here -- there's an African child dying of malaria. You don't even have to go to Africa. Here's a U.S. citizen who can't afford health care who has uncontrolled hypertension and diabetes, whose life will be shortened by many years. And here is David Koch with his billions. Do you have a problem with that?

Here's the cold, hard truth. Resources are scarce. The amount that it is politically possible to spend on health care, however it's financed and organized, is finite. Within that finite budget, we should allocate our resources to get the best overall result. That means we should not spend huge sums on treatments with small benefits at the cost of inexpensive, more effective treatments. Why? Because human life is precious.

Note that NICE is not actually a death panel in that it does not rule on individual cases. It doesn't say Joe should live and Sally should die. It says that the National Health Service won't pay for a particular drug for a particular indication, for anybody, or perhaps for anybody above a certain age. If you have the dough and you want to buy it on your own, you are free to do so.  This is unavoidable if you are going to provide health care to everybody.

But the way we do it in the U.S. is that we require insurance to pay for any FDA approved treatment, no matter what the cost, no matter how little the benefit. If, however, you can't afford insurance, you will be the one to suffer or die. However, the evaluative institutions established by the Affordable Care Act - the Independent Medicare Payment Advisory Board and the Patient Centered Outcomes Research Institute - are by law forbidden to take cost into account. Because Republicans think it would be immoral to do so. They also think it is immoral to tax rich people to pay for child care and higher education and medical care for low and moderate income people. Sort that out, if you can.


Anonymous said...

I saw how Caremark and Express scripts no longer offer 50 plus meds. Meds for cancer, heart disease, asthma...this is not stuff for a cold, but chronic illness. My MIL now has to pay $80 for Diovan. Why? Because she is in her seventies and not seen as worth saving? Or is it because Big Pharmaceutical in the US is allowed to rule over us with an iron fist? If you get cancer and choose hospice, medicare ceases to supply you with meds, like blood pressure pills that you had been using, bevause well, you are on your way out.
It is disgusting and I don't understand why more people are not appalled and pissed about it. Frigging Soylent Green coming to fruition.

Cervantes said...

Well hold on now. You choose hospice -- that's the whole point, you choose palliative care only. You don't have to, it's an option.

As for Caremark and Express Scripts, insurers set their formularies based on agreements they make with drug companies. It has nothing to do with cost-effectiveness calculations, they're just trying to save money. They will offer other drugs within the class with lower co-pays. The issue with your mother-in-law is the Part D plan she chose. Obviously it was the wrong one for her. This is a problem with Part D, it's ery hard for consumers to navigate, but it has nothing to do with cost-effectiveness analysis. This is really a whole different set of issues.