4 ms·

Can you explain in a bit more detail how NICE guidelines are similar to what is described in the article?

DanBC 7y ago
Firstly I'm only speaking about England. I don't know what happens in Wales, Scotland, or Northern Ireland. Clinical Commissioning Groups should be following NICE guidance. If NICE looks at a medication and says it doesn't provide enough advantage for the cost they won't recommend it. That means CCGs won't always pay for it, and so hospitals can't use it. Sometimes when NICE recommends a treatment the patient has a legal right to it, and the patient can pursue treatment if their local CCG is trying to avoid paying for it. This cost:benefit calculation appears to be what's happening in the US. Except over here it's a public body making the decision and over there it's a private company. Here's the NICE page for Pomalyst: https://www.nice.org.uk/guidance/ta427 https://www.nice.org.uk/guidance/ta427 > Pomalidomide, in combination with low‑dose dexamethasone, is recommended as an option for treating multiple myeloma in adults at third or subsequent relapse; that is, after 3 previous treatments including both lenalidomide and bortezomib, only when the company provides pomalidomide with the discount agreed in the patient access scheme. That seems similar to the US? Only to be used after other meds have been tried, and only if the company supplies it at a previously arranged discount. (I didn't do much searching for this so maybe I've misunderstood the NICE guidance). https://www.nice.org.uk/corporate/ecd4 https://www.nice.org.uk/corporate/ecd4 > If NICE recommends the use of a treatment, the NHS Constitution says that it is your legal right to have it if your doctor believes it is right for you. https://www.gov.uk/government/publications/the-nhs-constitution-for-england/the-nhs-constitution-for-england#patients-and-the-public-your-rights-and-the-nhs-pledges-to-you https://www.gov.uk/government/publications/the-nhs-constitut... > You have the right to drugs and treatments that have been recommended by NICE for use in the NHS, if your doctor says they are clinically appropriate for you. And here's a list of those treatments: https://www.nice.org.uk/guidance/published?type=hst,ta https://www.nice.org.uk/guidance/published?type=hst,ta
Scoundreller 7y ago
UK has a set of standard guidelines for how to treat diseases with proven drugs, and only pays for those (like the insurance company in the article being rigid about its guidelines). People complained that their doctors weren't allowed to go off-track and make up special treatments for their special patients that went against guidelines (like the patients in the article). Because it's political suicide to deny "What the doctor thinks is the best" when it comes to dying cancer patients, the UK government set up a special fund of money to let doctors go against the guidelines. It accounted for ~1/6th of all cancer drug costs. It turns out that this special fund was largely a waste of money, the guidelines were fine all along, and patients were harmed by getting treatments that don't work. Despite having our hearts in the right places, patients were harmed, and funds were taken out of some other (proven) part of the health care system. But because we tried to help, we won't bring this up very often.
- sorokod 7y ago
  And this relates to the article how? Ultimate, what is described is an insurer tying to minimize the payout on a claim same as they have been doing from the dawn of time except here it's particularly nasty as people suffer and die.
  - deleted 7y ago
    [deleted]
  - Scoundreller 7y ago
    The beef in the article seems to be "We're not paying for it, because it's not in our guidelines" vs. "Doctor thinks this patient is more special than the guidelines" Where in the article says that the insurance provider was trying to minimize the payout on the claim? Insurance companies really hate paying for things that don't work (or have a low likelihood of working). Even more than paying for something expensive that works. The article is really annoying, because Treatment A didn't work, and they wanted to skip Tx B and go right to Tx C. Tx C worked, but the article never named any of the drugs, so we can't evaluate the validity of this guideline. We just have one anecdote of one event where doctor was ultimately right (because nobody runs to the LA Times when they were in-the-wrong).
    - sorokod 7y ago
      > "“So we get a phone call here to my staff saying that the pharmacist – not the doctor, but the pharmacist – to the PBM called and said they are denying the drug.” The reason given: The patient should have surgery to remove his kidney first."
      - Scoundreller 7y ago
        Notice that the doctor didn't disagree with that being a course of treatment for this disease. Their response was that the patient was too ill for that surgery - a detail that wasn't known to the PBM. Either the issue is: 1) Kidney removal shouldn't be a course of treatment (unknown based on the details provided). Keep in mind, the same insurer would be paying for this, and it isn't cheap, so it's not as ridiculous as it sounds. 2) Patient status with regards to surgery wasn't communicated to the payor, but should be a part of that process. Or it was a part of the process, but it was omitted. 3) Kidney removal should be a course of treatment, but the doctors didn't want to go through with it anyway, and made up some reason after-the-fact to continue to support their beliefs.

Firstly I'm only speaking about England. I don't know what happens in Wales, Scotland, or Northern Ireland. Clinical Commissioning Groups should be following NICE guidance. If NICE looks at a medication and says it doesn't provide enough advantage for the cost they won't recommend it. That means CCGs won't always pay for it, and so hospitals can't use it. Sometimes when NICE recommends a treatment the patient has a legal right to it, and the patient can pursue treatment if their local CCG is trying to avoid paying for it. This cost:benefit calculation appears to be what's happening in the US. Except over here it's a public body making the decision and over there it's a private company. Here's the NICE page for Pomalyst: https://www.nice.org.uk/guidance/ta427 https://www.nice.org.uk/guidance/ta427 > Pomalidomide, in combination with low‑dose dexamethasone, is recommended as an option for treating multiple myeloma in adults at third or subsequent relapse; that is, after 3 previous treatments including both lenalidomide and bortezomib, only when the company provides pomalidomide with the discount agreed in the patient access scheme. That seems similar to the US? Only to be used after other meds have been tried, and only if the company supplies it at a previously arranged discount. (I didn't do much searching for this so maybe I've misunderstood the NICE guidance). https://www.nice.org.uk/corporate/ecd4 https://www.nice.org.uk/corporate/ecd4 > If NICE recommends the use of a treatment, the NHS Constitution says that it is your legal right to have it if your doctor believes it is right for you. https://www.gov.uk/government/publications/the-nhs-constitution-for-england/the-nhs-constitution-for-england#patients-and-the-public-your-rights-and-the-nhs-pledges-to-you https://www.gov.uk/government/publications/the-nhs-constitut... > You have the right to drugs and treatments that have been recommended by NICE for use in the NHS, if your doctor says they are clinically appropriate for you. And here's a list of those treatments: https://www.nice.org.uk/guidance/published?type=hst,ta https://www.nice.org.uk/guidance/published?type=hst,ta

Scoundreller 7y ago

UK has a set of standard guidelines for how to treat diseases with proven drugs, and only pays for those (like the insurance company in the article being rigid about its guidelines). People complained that their doctors weren't allowed to go off-track and make up special treatments for their special patients that went against guidelines (like the patients in the article). Because it's political suicide to deny "What the doctor thinks is the best" when it comes to dying cancer patients, the UK government set up a special fund of money to let doctors go against the guidelines. It accounted for ~1/6th of all cancer drug costs. It turns out that this special fund was largely a waste of money, the guidelines were fine all along, and patients were harmed by getting treatments that don't work. Despite having our hearts in the right places, patients were harmed, and funds were taken out of some other (proven) part of the health care system. But because we tried to help, we won't bring this up very often.

sorokod 7y ago
And this relates to the article how? Ultimate, what is described is an insurer tying to minimize the payout on a claim same as they have been doing from the dawn of time except here it's particularly nasty as people suffer and die.
- deleted 7y ago
  [deleted]
- Scoundreller 7y ago
  The beef in the article seems to be "We're not paying for it, because it's not in our guidelines" vs. "Doctor thinks this patient is more special than the guidelines" Where in the article says that the insurance provider was trying to minimize the payout on the claim? Insurance companies really hate paying for things that don't work (or have a low likelihood of working). Even more than paying for something expensive that works. The article is really annoying, because Treatment A didn't work, and they wanted to skip Tx B and go right to Tx C. Tx C worked, but the article never named any of the drugs, so we can't evaluate the validity of this guideline. We just have one anecdote of one event where doctor was ultimately right (because nobody runs to the LA Times when they were in-the-wrong).
  - sorokod 7y ago
    > "“So we get a phone call here to my staff saying that the pharmacist – not the doctor, but the pharmacist – to the PBM called and said they are denying the drug.” The reason given: The patient should have surgery to remove his kidney first."
    - Scoundreller 7y ago
      Notice that the doctor didn't disagree with that being a course of treatment for this disease. Their response was that the patient was too ill for that surgery - a detail that wasn't known to the PBM. Either the issue is: 1) Kidney removal shouldn't be a course of treatment (unknown based on the details provided). Keep in mind, the same insurer would be paying for this, and it isn't cheap, so it's not as ridiculous as it sounds. 2) Patient status with regards to surgery wasn't communicated to the payor, but should be a part of that process. Or it was a part of the process, but it was omitted. 3) Kidney removal should be a course of treatment, but the doctors didn't want to go through with it anyway, and made up some reason after-the-fact to continue to support their beliefs.