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How much is a year of your life worth?
How much is a year of your life worth?
Wisconsin State Journal
The politics of health care certainly make for strange bedfellows.
Nearly 15 years ago, when then-First Lady Hillary Clinton proposed to restructure American health care in the image of the European and Canadian systems, most health insurance providers blasted her plan.
What a difference a few years make. Just last month, Sen. Clinton and the very same insurers -- in their current incarnation as a trade group called America's Health Insurance Plans -- stood shoulder-to-shoulder in support of such a scheme. Their plan would give the federal government the power to determine what new medicines and services to cover based on budgetary considerations.
So what's changed? Not Sen. Clinton -- she has always regarded government as the best arbiter of health care value.
It's the health insurers who have flipped, thinking the scheme will help them save a few bucks.
The model for this marriage of old foes is Britain's National Institute for Clinical Excellence (NICE), which employs comparative effectiveness studies in evaluating whether to pay for new and often expensive medicines.
More often than not, NICE recommends against using the new treatment because it's not "cost-effective" when compared to existing treatments.
That's why many Britons refer to NICE as "NASTY" -- "Not available, so treat yourself."
One drug rejected or rationed by NICE is Gleevec, which targets stomach cancer. In 2001, Gleevec immediately became a frontline therapy in the United States for this incredibly painful disease. NICE, on the other hand, took three years to decide that it would use Gleevec only as a last resort, in limited doses -- much to the outrage of cancer specialists and patients.
NICE has also recommended against Herceptin, an extremely effective treatment for breast cancer, and drugs that treat osteoporosis, Alzheimer's, and multiple sclerosis. And it's not just NICE that isn't living up to its acronym. Government review agencies in Australia, New Zealand, and Canada have similarly declined coverage of expensive breakthrough treatments.
And how do these panels perform that grim calculation? Through something called a "quality of life-year" (QALY), which represents the estimated dollar value of an additional year of healthy life.
In Britain, government officials assume that an additional QALY is worth about $50,000 -- the average price of a fully loaded Land Rover. Not only is this figure strikingly low on its face, but the deck is already stacked against the new, more expensive medicines. Because most new therapies are first tested in the critically ill, it's almost impossible to see significant improvements in a patient's prospects with his or her condition already so dire.
Thankfully, the QALY hasn't yet taken hold in U.S. government decision-making. But by looking to foreign systems that base their medical decisions on such metrics for inspiration, Sen. Clinton and many health insurers are moving medicine backward.
The fact is that by using a combination of cutting-edge information technology and genetic tests, doctors can do a better job than any cost-benefit agency of ensuring that patients get the right treatment at the right time. Many new drugs, including top-selling cancer drugs like Tarceva and Avastin, already incorporate genetic testing into their prescription. Such testing will allow doctors to transition to the long-awaited era of personalized medicine.
And with personalized medicine comes true individual control over health care decisions. This is anathema to Sen. Clinton and her new allies in the insurance industry. Both take as an article of faith that large interests -- whether government or big business -- can best determine how health care should be delivered in America.
As health care costs have risen, many policymakers and insurance industry elites have declared that innovative and life-changing new treatments are not worth the price. What a disaster it would be for medical innovation if a narrow-minded focus on cost took precedence over new treatments, new drugs, and personalized health care decision-making.
Pitts is president of the Center for Medicine in the Public Interest and a former FDA Associate Commissioner. |
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