December 4, 2008

The British Model Of Cost Effectiveness Fails On Philosophy

Good idea, sort of, but it misses a key element.

The NYT has an article which, for some reason, is entitled "The Evidence Gap." 

The British National Institute for Health and Clinical Excellence (NICE) uses evidence based methods to determine whether a drug is worth the cost.  Th example they site in the article is a new kidney cancer drug that costs 3 to 4 times more than NICE has budgeted for that disease state.  NICE uses quality adjusted life year to determine a treatment's merit, and then weighs it against the cost.  According to the article, it's about $20k per six months of life.

Ia.  What Price Life?

Certainly people are outraged; life is worth any price.  Unfortunately, no one seems to have the courage to say this, use it as a first principle.  Instead, NICE says this: 

Equity lies at the heart of the NHS. Lack of equity...  was one of the reasons why NICE was established. Much of the philosophical literature on equity is far from being applicable to the real world.18,19 NICE has therefore had to make its own judgments.

Yet another group of doctors who believe they are living at The End Of History. Whenever I hear, "this time it's different" or "the old way of thinking doesn't apply" I know to expect the opposite to occur.

Ib. What Price Life?

But the argument over "what price life" is a red herring, the real question is "who best to decide how to allocate resources? and the answer (IMHO) is not government, but doctors.

The main support for the government plan is that it lowers drug costs.  First, by restricting the use of certain meds, and second (from the NYT:)

Drug and device makers, which once routinely denounced the British for questioning product prices, have begun quietly slashing prices in Britain to gain NICE's coveted approval, especially because other nations are following the institute's lead.

Aha.  Pharma voluntarily lowers prices to be able to fit within the government's budget.  How much more effective would this be if they had to cut it to fit within the doctor's "patient budget" by which doctors are told there's a certain amount they can spend

Additionally, creating a budget for doctors will force Pharma to start creating drugs that fit into the budget.  So either the cost will come down, or they'll create something that's worth the cost.

But what about those patients who need more than their budget?  Simply allow a "prior authorization" system by which a doctor can call the insurer/Medicair to expand the budget, and he can cite his reasons.  Oh, it's a pain?  That's the point.  If it is really worth it, it will be worth it.  And make it so the doctor can even bill for the time.  The obstacle alone will greatly reduce "impulse buying" of meds ("I wanna try Pristiq!") Consider that simply having a discussion with a reviewer-doctor alone is worth the government's effort, because there are docs who never get a chance to talk to anyone except a rep about what's going on in medicine.  Hell, offer CME credit for the discussion.

II.  What Price Autonomy?

But why not let the government control the budget?  What advantage is there in giving it to the doctors?

  1. Autonomy.  Doctors don't want to be dictated to by government.  Since we must unfortunately have some sort of control plan, give as much control to the doctors as possible.  Consider that if medicine becomes so flow-charted, so controlled from the outside, then smart people will not be interested in becoming doctors.
  2. Education.  If they have to decide what's worth it, they'll have to stay current.  Even if the flow-chart tells you exactly what to do next, do you really want a doctor who doesn't have a full understanding of the issues?
  3. Alternatives.  Doctors may actually try to use non-pharmacologic treatments.  The horror!  I have a question: if diet can lead to bad health, why can't a good diet lead to not just neutral, but better health?  Why can't a food be as good for you as some are bad for you?  e.g. if Big Macs are bad for your cholesterol, what foods would lower cholesterol?  Doctors are not trained to think that way anymore.
  4. The government is not a doctor.  Neither are the people in NICE or any other body that determines cost-effectiveness.  Oh, I know they're MDs, but they're not "on the ground" doctors.  Their focus is not reality based.
  5. Corruption.  If a doctor is "corrupted" by Pharma (or his own academic interests, or political bias, etc) then that's one.  If NICE/FDA gets corrupted by Pharma (or their own academic interests, or political bias) then that's the game.  If you want to see what top down bias looks like, it looks like Depakote.

III.  What Price Dignity?

British authorities, after a storm of protest, are reconsidering their decision on the cancer drug and others.

So we see that when the drug deals with acute survival, there is controversy.  Ok, Perhaps the model shouldn't be applied to those drugs, at least not at first.  But it most certainly can be applied to psychiatry, for which there is no evidentiary, logical, or even anecdotal reason to think that any one medicine is necessary at any cost-- hell, at even double the cost.  (I'd grant you lithium and clozapine, but they're already generic.)

I know, I know, "doctors already have too much to worry about, they can't be busy with drug costs."  Too bad.  Seriously: too the hell bad.  The current system is untenable, something must change.  If you don't like this plan, then you will have a government plan.  See II, above.

The budget needs to go to the doctors; and then doctors need to get together and start learning again.  Set up advisory panels, put the academics to work on something real, instead of silly clinical trials which are biased-- not just by Pharma, but by their own desire for advancement.  "I believe in antiepileptics."  Awesome.


Autonomy. Doctors don't wa... (Below threshold)

December 5, 2008 10:14 PM | Posted by mark p.s.2: | Reply

Autonomy. Doctors don't want to be dictated to by government.

Funny, funny line from a psychiatrist, as psychiatrists can be a dictator to his/her mentally ill "patients".

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I dunno, doc.I see... (Below threshold)

December 6, 2008 7:09 AM | Posted by Savage Henry: | Reply

I dunno, doc.

I see why you advocate for the doctors to dictate where the money is spent. It appears to be the best solution. However, it seems to me a smart doc with a long term view is going to stay the hell away from rationing health care. There is no way to preserve any esteem or respect with the public at large once an organization/profession begins doing that.

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Speaking as a consumer/pati... (Below threshold)

December 9, 2008 12:43 PM | Posted by La BellaDonna: | Reply

Speaking as a consumer/patient, I can state categorically I haven't been happy when the insurance company - which has never met me, examined me, reviewed my medical records, etc. - decides IT KNOWS BETTER THAN MY DOCTOR what should be prescribed for me, and how often, or in what manner - in the face of my doctor's decisions, and based on no supporting evidence whatsover with regard to my medical condition.

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You're probably aware of th... (Below threshold)

January 26, 2009 2:14 PM | Posted by Matt: | Reply

You're probably aware of this, but Britain's healthcare is nationalised. It is owned by the government and run on tax payer's money. It is also in severe debt. If the government wanted to spend big money on new expensive pills, it would be at the expense of the people. Tax payers don't want to pay for some stranger to have a longer life, they want less taxes. NICE, may just be to control medicines by value but by putting healthcare into the hands of politicians, there is no other option. To put your ideal model into practice you would have to piss off every socialist in Britain.

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Oh I realize this post is 5... (Below threshold)

February 20, 2013 11:36 PM | Posted by Art: | Reply

Oh I realize this post is 5 years old, but I like your blog and I think you make a lot of sense on many topics but here's why this wouldn't work:
An average family doc (at least here in Canada) has around 2000 patients. An average patient visits her family doc about 3 times per year (some more some less). If the doc works 250 days a year that works out to 3.2 patients per hour (2000 x 3 / 250 days / 7.5 working hours in a day). So that's about 20 min per patient.

There are about 1200+ prescription drugs on the Canadian market + hundreds of over-the-counter drugs + 60,000 plus natural health products (vitamins etc.) Even pharmacists have a hard time keeping track of the costs of all of this. If an average family doc had to consider his "drug budget" with every patient she would fail miserably.

Why? How much does the drug cost? How much does the wholesaler and then the pharmacy mark it up? How much does the pharmacy charge for dispensing the drug? How much does the drug cost today versus what it was 6 months ago (drug prices fluctuate quite a bit)?

So, inevitably that average family doc would have to hire/outsource to someone else to manage her "drug budget".

So initially this would be an admin assistant, but she would have little access to drug pricing (especially the variability between pharmacies). So then pharmacies would inevitably offer consulting services to streamline the doctor's "budget". Fast forward and some of these would essentially turn into what are now insurance companies/formularies. Fast forward a bit more and we're back to square one - someone else deciding for the doctor how much to budget for the drugs.

Large companies usually have full time staff as "purchasing" experts because no one else has a good grip on the cost of things. The world of healthcare did this a long time ago by making pharmacies and formularies as the de facto purchasing experts. If we compare doctors to CEO's of companies, then it would be silly to think that CEO's would be making purchasing decision about every single product in their company.

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