5 ms·

If anyone's interested, England's system of health technology assessment (HTA) for the NHS is extremely transparent and world-leading. It's one of the things t

by Apfel 10y ago

If anyone's interested, England's system of health technology assessment (HTA) for the NHS is extremely transparent and world-leading. 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-case https://www.nice.org.uk/process/pmg9/chapter/the-reference-c...

grabcocque 10y ago
The interesting thing about NIHCE and its short existence is that it's a startling reminder that the idea that health policy should be evidence-based is still a new one. 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.
- Apfel 10y ago
  Just for the record, although the acronym does technically spell out NIHCE since they changed the name, they've stuck with the "NICE" branding. 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/v031p00373.pdf https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1734179/pdf/v03... [ii] http://www.nature.com/bdj/journal/v215/n5/full/sj.bdj.2013.832.html http://www.nature.com/bdj/journal/v215/n5/full/sj.bdj.2013.8...
chimeracoder 10y ago
> 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). They consider everything in a wider context of opportunity cost of adopting a new treatment and budget constraints. 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.
- sharemywin 10y ago
  -> that assumes that government agencies don't have a profit motive just because they that's not recorded on their balance sheet (they do) As long as you say so. Every must agree.
- sharemywin 10y ago
  At the end of the day if you don't have the money to pay for a treatment yourself then someone else is making a cost to benefit analysis.
  - chimeracoder 10y ago
    > At the end of the day if you don't have the money to pay for a treatment yourself then someone else is making a cost to benefit analysis. 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.
- DanBC 10y ago
  You're confusing two different things. 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.
  - chimeracoder 10y ago
    > You're confusing two different things. 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. 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.
refurb 10y ago
I would argue HTA is not without it's problems. That's why the UK has a cancer drug fund. NICE has said "no" to those drugs, yet the public still clammers for them. So a separate funding mechanism was created to pay for them.[1] [1]https://www.england.nhs.uk/cancer/cdf/ https://www.england.nhs.uk/cancer/cdf/
- chimeracoder 10y ago
  > I would argue HTA is not without it's problems. That's why the UK has a cancer drug fund. NICE has said "no" to those drugs, yet the public still clammers for them. So a separate funding mechanism was created to pay for them. 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
  - DanBC 10y ago
    Sexual health is part of public health, and thus we'd expect PrEP to be funded by Public Health England, not the NHS. The target of your anger here should be local authorities (who hold responsibility for Public Health), not the NHS. https://www.england.nhs.uk/2016/11/update-on-prep/ https://www.england.nhs.uk/2016/11/update-on-prep/
    - chimeracoder 10y ago

by Apfel 10y ago

grabcocque 10y ago

The interesting thing about NIHCE and its short existence is that it's a startling reminder that the idea that health policy should be evidence-based is still a new one. 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.

Apfel 10y ago
Just for the record, although the acronym does technically spell out NIHCE since they changed the name, they've stuck with the "NICE" branding. 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/v031p00373.pdf https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1734179/pdf/v03... [ii] http://www.nature.com/bdj/journal/v215/n5/full/sj.bdj.2013.832.html http://www.nature.com/bdj/journal/v215/n5/full/sj.bdj.2013.8...

chimeracoder 10y ago

> 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). They consider everything in a wider context of opportunity cost of adopting a new treatment and budget constraints. 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.

sharemywin 10y ago
-> that assumes that government agencies don't have a profit motive just because they that's not recorded on their balance sheet (they do) As long as you say so. Every must agree.
sharemywin 10y ago
At the end of the day if you don't have the money to pay for a treatment yourself then someone else is making a cost to benefit analysis.
- chimeracoder 10y ago
  > At the end of the day if you don't have the money to pay for a treatment yourself then someone else is making a cost to benefit analysis. 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.
DanBC 10y ago
You're confusing two different things. 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.
- chimeracoder 10y ago
  > You're confusing two different things. 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. 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.

refurb 10y ago

I would argue HTA is not without it's problems. That's why the UK has a cancer drug fund. NICE has said "no" to those drugs, yet the public still clammers for them. So a separate funding mechanism was created to pay for them.[1] [1]https://www.england.nhs.uk/cancer/cdf/ https://www.england.nhs.uk/cancer/cdf/

chimeracoder 10y ago
> I would argue HTA is not without it's problems. That's why the UK has a cancer drug fund. NICE has said "no" to those drugs, yet the public still clammers for them. So a separate funding mechanism was created to pay for them. 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
- DanBC 10y ago
  Sexual health is part of public health, and thus we'd expect PrEP to be funded by Public Health England, not the NHS. The target of your anger here should be local authorities (who hold responsibility for Public Health), not the NHS. https://www.england.nhs.uk/2016/11/update-on-prep/ https://www.england.nhs.uk/2016/11/update-on-prep/
  - chimeracoder 10y ago