It's one of the things that we Brits should be extremely proud of (although pharma-sponsored sob story campaigns in tabloid newspapers may suggest otherwise).
All new technologies are investigated in terms of incremental quality of life gain (vs current treatment norms) and changes in costs.
Furthermore, they consider everything in a wider context of opportunity cost of adopting a new treatment and budget constraints.
For a lot more detail, have a look at the NICE reference case here: https://www.nice.org.uk/process/pmg9/chapter/the-reference-c...
NIHCE's greatest contribution has been that, in insisting on being evidence-based as de-politicised any and all questions about what treatments should be available.
I think this week's US shenanigans have showed that de-politicising healthcare is a very laudable goal.
It allows for all sorts of pun titles for academic papers like the following:
[i] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1734179/pdf/v03...
[ii] http://www.nature.com/bdj/journal/v215/n5/full/sj.bdj.2013.8...
The lobbyist who devised the value proposition to Cameron's government must be very proud of him/herself.
The only reason the public clamours for these drugs is because opportunity cost of treatment is very hard to distill into a newspaper headline.
The cancer drugs fund, at base principles, implies that cancer patients lives are more valuable than the rest of the public.
See also: PrEP. PrEP is available in the US (and covered by almost every private insurer[0] with drug co-pays covered by the manufacturer[1]). And while it's less convenient, there are public clinics where you can get prescriptions to avoid paying the co-pay to a GP. In other words, absent the cost of your time, you can get it in the US for free.
In the UK, PrEP is not covered by the NHS. The National AIDS Trust had to sue the NHS just to get them to announce their decision not to cover it - before that, they refused to make a statement one way or the other, and kept kicking the can down the road. Now, you can only get it by paying a private doctor (out-of-pocket) for a prescription, and then fill that prescription privately, which can cost up to $13/pill.
(This is technically not HTA, but for the purposes of this discussion that distinction isn't relevant.)
[0] And, as an aside, on the rare case that your insurer does not cover it, Gilead (the manufacuter) offers assistance programs that provide it essentially for free.
[1] This is a separate program to enroll in; Gilead basically reimburses the co-pays that the insurers charge
The target of your anger here should be local authorities (who hold responsibility for Public Health), not the NHS.
First, PHE and NHS are both part of the DH, as is NICE.
Second, sexual health is one aspect of PrEP, but it's not the full picture (though of course, that's how the NHS press release you linked would be inclined to portray it. The lower court disagreed with that portrayal, even if the appeals court did not.)
Finally, the arbitrary delineation of responsibilities in which the NHS is free to wash its hands off of the matter and NICE has no incentive to hold the NHS accountable - leaving patients with no choice but to pay out-of-pocket - is exactly the problem. Meanwhile, PrEP has been generally available (and essentially free) in the US for four years, thanks (ironically) to the federation of power which forces insurers to remain somewhat competitive with each other, and which permits the pharmaceutical companies to pick up the slack when that fails.
If you want to point out that this approach has its shortcomings as well, then yes, I'm right there with you. But it's wrong to imply that what NICE and the NHS are doing is fundamentally different from the cost-benefit analyses done in the US, and it's also wrong to ignore the problems with the DH.
For context, this is literally what risk-bearing entities in the US already do (both insurers and at-risk providers).
I could get behind the statement that risk-bearing entities should be performing methodical cost-benefit analysis of care coverage, but the fact remains that, at the end of the day, that means that someone is making the decision to deny certain people coverage because it's not cost-effective. Whether you have clinicians and analysts at an insurance insurance company performing that role or the government clinical panel of clinicians and analysts performing that role, it still results in some people having their care approved and some having their treatments denied[0].
It's weird to then dismiss the negative side of the tradeoffs as "pharma-sponsored sob story campaigns" in the UK, when those same stories are accepted as evidence of the systemic problems within the US.
[0] And to pre-empt the common misguided criticism that "it's better because it's not a for-profit company making the decision", that assumes that government agencies don't have a profit motive just because they that's not recorded on their balance sheet (they do), and it also forgets the counterintuitive fact that the explicit profit incentive in the US actually incentivizes the company to permit claims on more expensive treatments if the patient requests them.
When NICE decides not to fund something they have clear evidence that it is worse than current treatment, not just that it is more expensive than current treatment.
See, for example, Abraxane, a chemotherapy for pancreatic cancer.
To be accepted all it has to do is either:
i) Be better than current first line treatment or
ii) Have less side effects, and thus be usable as a second line treatment or
iii) Be much cheaper
It's fantastically expensive, has many side effects, and is less effective than current treatment. So it fails all three. But you wouldn't be able to tell that from the pharma-sponsored advocacy groups. Those groups talk about "2 years of life", when the manufacturer's own data talks of just 3 weeks.
It's incorrect to say that NICE has a profit motive. They very clearly - and this is the point of transparency - don't.
That's not true at all. Kadcyla is superior to current therapies for HER+ breast cancer. NICE has decided not to fund it because it's too expensive.[1]
But the reality is that the price of Kadcyla is currently too high in relation to the benefits it gives for it to be recommended for routine commissioning in the NHS, even taking into account the end‑of‑life criteria and the patient access scheme.”
[1]https://www.nice.org.uk/news/article/kadcyla-too-expensive-f...
No, I'm not confusing two different things, and I'm glad you picked cancer as an example.
Even if NICE has approved a treatment as "cost-effective", that doesn't mean that any specific patient will actually be eligible to receive it. For cancer treatments, there is a separate panel which reviews individual cases and provides the options available to that patient. It is not done on the aggregate; it's determined on the individual level. And, to make matters worse, if the patient decides to deviate sufficiently from the treatment plan (perhaps by delaying chemotherapy, or seeking treatment abroad first), those options can be rescinded, at which point the patient is required to pay out-of-pocket on the private market.
> It's incorrect to say that NICE has a profit motive. They very clearly - and this is the point of transparency - don't.
Every agency in every country, public or private, has a profit motive, and the DH is no exception. Transparency doesn't eliminate the profit motive; it just provides visibility into both the inputs and the outputs.
Exactly, that's the point. You can label it however you want, and set up whatever system you want to allocate the resources, but that doesn't change the fact that this decision has to be made.
As long as you say so. Every must agree.
The easiest way to fix the fact that 'they can' would be to permit re-importating drugs that were manufactured within the US.
Shortly before Obama left office, there was a bill that would have fixed that, but nine Democrats joined the Republicans in voting it down: https://www.senate.gov/legislative/LIS/roll_call_lists/roll_...
If I'm Pfizer, why on earth would I dramatically increase my sales of drugs to Canada knowing they're just going to be reimported into the US?
The answer is, I wouldn't. I would put a quota on Canadian sales. Sell them enough drugs for Canadians. This was actually done about a decade ago when reimportation was more popular.
That's the thing about governments: they can do whatever they want. And your recourse is to deal with it or spend years fighting against it (or die in the streets fighting it, lest we forget that option).
Disclaimer: I'm for breaking patents when necessary, although 3D printing drugs is around the corner making it a moot point.
EDIT: @refurb:
I love coming to HN and having people say "its too hard, it'll never be done". ;)
I can run the laser sintering machine in my garage and build metal parts from a fine powder, parts that are aircraft grade, but I won't be able to 3D print drugs at home? No imagination.
3D drug printing is a pipe dream. The syntheses are way to complex to do at home. You'd be better of just having a CRO make the drug for you.
https://www.washingtonpost.com/news/innovations/wp/2015/08/1...
3D printing of tablets containing multiple drugs with defined release profiles (2015)
http://www.sciencedirect.com/science/article/pii/S0378517315...
I can Google. You should Google before making a false blanket statement.
The issue is creating the active compound, not putting it into pill form.
The US has plenty of market power to reduce prices for drugs sold in the US. There are reasons to be in favor of wielding that market power and there are reasons to be against it. But there is no rational reason to pretend to not wield it but then re-import a bunch of drugs from Canada. That's just a waste of shipping costs.
Permitting trade across the US-Canadian border provides an equalizing force on the prices across the border, even though no drugs actually need to make the return trip (at equilibrium).
In other words, allowing the trade puts an upper bound on the difference between the prices charged in the US and the prices charged in Canada - that difference can be no greater than the costs of reimporting those drugs, or else it's cheaper for people to source their drugs from Canada.
By disallowing the trade, we allow the difference to grow unbounded.
Here's the same idea, introduced as a bill instead of an amendment, and being co-sponsored by several of the amendment's "Nay" votes: https://www.congress.gov/bill/115th-congress/senate-bill/469
The drug market is one of the farthest things we have from a free market in the US outside of military weapons. It is just massively dysfunctional due to a combination of special interest lobbying combined with stepwise path-dependency.
A huge part of the health care discussion in the US starts from assuming our current system is somehow natural. It isn't. It is an engineered thing, with the engineering performed by in a non-coordinated fashion with incompatible goals by non-experts, piecewise, over a long period of time.
Even though I doubt it (healthcare truly is different than most services/goods), a truly free market might even be superior to what we have, in terms of outcomes by patient count. Of course, that would lead to unsightly public corpses, a much different drug industry and a lot of unemployed clerical workers, among other things.
And the big, unanswered question remains: why the US is such a special snowflake that what works in various ways in every other first-world country cannot work here. (Aside from the obvious answer.)
I don't care for this argument simply because the US was the first country to throw off monarchical rule. Why the need for homogeneity? Shouldn't we have as many different implementations as possible? Personally, I don't care for centralized power (i.e. Facebook).
Didn't Google take a different approach to site ranking than every other search engine? If people want to see what state-level healthcare looks like, check out MA (so-called Romney-care). We had an amendment to the CO state constitution this past election that I voted for, but ultimately failed.
I'm sorry you don't like it. We have an interesting history, but I do fail to see the relevance of a centuries-old political dispute to the question of modern healthcare policy[0].
> Why the need for homogeneity?
This is a strange question. This seems to presuppose that all other first-world countries have identical single-payer or something. The structure of healthcare in the developed world takes many different forms - see [1] for a sampler. All of them work better than what we have, for cheaper.
Personally, I'd be fine with any of those models. Or, if you have a new one, please, let's hear it - just about anything is going to be better than what we have[2].
> Shouldn't we have as many different implementations as possible?
Unless you want to throw a lot of money and lives away, no.
Generally, one experiments with different things in order to find out what works. We have a fairly decent, if not great, idea of things that work and things that don't. A huge swath of "things that don't" probably shouldn't be tried again, because that leads to suffering, death and wasted money. I'm all in favor of refining something that works into something that works better, and we should do that. But we need to get to the "something that works" part, first.
> Personally, I don't care for centralized power
Good. Me, too, and I think too few people feel that way. Unfortunately, if you're looking for decentralization in healthcare, you're still in the wrong country.[3]
Bottom line for me: If, in fact, the U.S. is supposed to be exceptional, supposed to be showing the way, supposed to be a better place, why do we tolerate a sixth of our economy being a shit-pit of waste, misery and dysfunction?
[0] For the pedantic, modulo constitutional issues, path-dependence through legal precedent, convincing people that somehow our government/land/people/animating spirit is so magically special that somehow economics, game theory and human nature don't apply to us, etc.
[1] https://en.wikipedia.org/wiki/Universal_health_care
[2] https://www.forbes.com/sites/danmunro/2014/06/16/u-s-healthc...
[3] http://www.allhealth.org/health-care-consolidation-trends-im...
Even the greatest monopoly of all time -- Standard Oil -- which at its peak had 96% market share was whittled down to 64% by competition by the time the "white knight" regulators had it broken up.
And who knows the long-term consequences of empowering the government to determine what is and isn't a monopoly? Well in the case of friendly relationships with well-lobbied corporate interests, there will probably not be any anti-monopoly action forthcoming.