How to ration Healthcare 101

[BridgeTroll]

Here is how the Brits do it... Very interesting reading.  Most Americans will have a hard time with this...

http://en.wikipedia.org/wiki/National_Institute_for_Health_and_Clinical_Excellence

National Institute for Health and Clinical Excellence
From Wikipedia, the free encyclopedia

The National Institute for Health and Clinical Excellence or NICE is a special health authority of the National Health Service (NHS) in England and Wales. It was set up as the National Institute for Clinical Excellence in 1999, and on 1 April 2005 joined with the Health Development Agency to become the new National Institute for Health and Clinical Excellence (still abbreviated as NICE).

NICE publishes clinical appraisals of whether particular treatments should be considered worthwhile by the NHS. These appraisals are based primarily on cost-effectiveness.

NICE was established in an attempt to defuse the so-called postcode lottery system of healthcare in England and Wales, where treatments that were available depended upon the NHS primary care trust area in which the patient happened to live. However its role in rationing treatment has led to NICE becoming a controversial body, which has gained a high profile internationally as a potential role model for the explicit prioritisation of health services[1].
[edit] Technology appraisals
Since January 2005 the NHS in England and Wales has been legally obliged to provide funding for medicines and treatments recommended by NICE's technology appraisal board. This is at least in part as a result of well-publicised postcode lottery scandals in which certain less-common treatments are funded in one part of the UK but not in another.

Before an appraisal the Advisory Committee on Topic Selection (ACTS) draws up a list of potential topics of clinical significance for appraissal. The Secretary of State for Health or the Welsh Assembly must then refer any technology so that the apprisal process can be formally initiated. Once this has been done NICE works with the Department of Health to draw up the scope of the appraisal.

NICE then invite consultee and commentator organisations to take part in the appraisal. A consultee organisation would include patient groups, organisations representing health care professionals and the manufacturers of the product undergoing appraisal. Consultees submit evidence during the appraisal and comment on the appraisal documents. Commentator organisations include the manufacturers of products to which the product undergoing appraisal is being compared. They comment on the documents that have been submitted and drawn up but do not actually submit information themselves.

An independent academic centre then draws together and analyses all of the published information on the technology under appraisal and prepares an assessment report. This can be commented on by the Consultees and Commentators. Comments are then taken into account and changes made to the assessment report to produce an evaluation report. An independent Appraisal Committee then looks at the evaluation report, hears spoken testimony from clinical experts, patient groups and carers. They take their testimony into account and draw up a document known as the 'appraisal consultation document'. This is sent to all consultees and commentators who are then able to make further comments. Once these comments have been taken into account the final document is drawn up called the 'final appraisal determination'. This is submitted to NICE for approval.

The process aims to be fully independent of government and lobbying power, basing decisions fully on clinical and cost-effectiveness. There have been concerns that lobbying by pharmaceutical companies to mobilise media attention and influence public opinion are attempts to influence the decision making process[2]. A fast-track assessment system has been introduced to reach decisions where there is most pressure for a conclusion.


[edit] Clinical guidelines
NICE carries out assessments of the most appropriate treatment regimes for different diseases. This must take into account both desired medical outcomes (i.e. the best possible result for the patient) and also economic arguments regarding differing treatments.

NICE have set up several National Collaborating Centres who draw up the boundaries of the guideline, i.e. what it will cover. The National Collaborating Centre then appoints a Guideline Development Group whose job it is to work on the development of the clinical guideline. This group will consist of medical professionals, representatives of patient and carer groups and technical experts. They work together to asses the evidence for the guideline topic (e.g. clinical trials of competing products) before preparing a draft guideline.

There are then two consultation periods in which stakeholder organisations are able to comment on the draft guideline. After the second consultation period an independent Guideline Review Panel reviews the guideline and stakeholder comments and ensures that these comments have been taken into account.

The Guideline Development Group then finalises the recommendations and the National Collaboration Centre produces the final guideline. This is submitted to NICE who then formally approve the guideline and issues this guidance to the NHS.


[edit] Cost effectiveness
NICE attempts to rationalise for the NHS the trade off between spending money on different forms of treatment and when and when not to treat. It attempts to weigh up factors such as how much benefit the treatment gives, how long the benefit of the treatment will last for, and how much it costs. Once it has done this it will make recommendations about which treatments can be given and in which circumstances in order to maximise the delivery of care within the available budget.


[edit] Quality-adjusted life years
NICE utililises the quality-adjusted life year or QALY to measure the benefits of a treatment quality and the quantity of life delivered by a given treatment regime. One interpretation of QALY would be how much lifespan a person would be prepared to give up to deliver one year of perfect health from the current state of ill health. By comparing QALY values before and after treatment one could calculate the benefit delivered by a given treatment to a given person[3].


[edit] Cost per quality-adjusted life year gained
The cost of a treatment may be relatively easy to calculate but because people may be at different ages when they receive treatment, the gain may be different according to age. A heart operation on a small child may deliver many more years of quality of life than the same operation on a 76 year old man. By taking the cost of treatment and dividing it by the years gained an overall cost benefit ratio can be determined as the 'cost per quality-adjusted life year gained' or CQG.

[edit] Basis of recommendations
Theoretically it might be possible to draw up a table of all possible treatments sorted by increasing the cost per quality-adjusted life year gained. Those treatments with lowest cost per quality-adjusted life year gained would appear at the top of the table and deliver the most benefit per value spent and would be easiest to justify funding for. Those where the delivered benefit is low and the cost is high would appear at the bottom of the list. Decision makers would, theoretically, work down the table, adopting services that are the most cost effective. The point at which the NHS budget is exhausted would reveal the shadow price, the threshold lying between the CQG gained of the last service that is funded and that of the next most cost effective service which is not funded.

In practice this exercise is not done, but an assumed shadow price has been used by NICE for many years in its assessments to determine which treatments the NHS should and should not fund. NICE states that for drugs the cost per QALY should not normally exceed £30,000 but that there is not a hard threshold[4]. However research has shown that any threshold is "somewhat higher" than this[5].

The cost per QALY above which a drug is unlikley to be approved by NICE is currently £30,000 + £45,000 [6]. There is also an argument that since the DHSS was split into the DSS and DOH, the true costs associated with illness (in terms of loss of earnings from patient and carers) are underestimated.[citation needed]


[edit] Criticism

The work that NICE is involved in attracts the attention of many groups, including doctors, the pharmaceutical industry, and patients. NICE is often associated with controversy, because the need to make decisions at a national level can conflict with what is (or is believed to be) in the best interests of an individual patient. Decisions not to fund expensive treatments or those with no proven benefits are necessary to ensure that public funds are used wisely. From an individual's perspective it can sometimes seem that NICE is denying access to a potentially life-saving treatment but the denial is only effective as far as the use of public resources are concerned. Treatment may be available if the patient can find the resources to pay for treatment in the private sector and a doctor willing to administer it.
NICE has been criticised for being too slow to reach decisions, especially when compared to the equivalent body for Scotland, the Scottish Medicines Consortium. On one occasion, the Royal National Institute of Blind People accused NICE of incompetence over its delayed decision to approve a drug already approved for use in Scotland[7].

Some of the more controversial NICE decisions have concerned Donepezil, galantamine, rivastigmine (review) and memantine for the treatment of Alzheimer's disease and Bevacizumab, sorafenib, sunitinib and temsirolimus for renal cell carcinoma. All these are drugs with a high cost per treatment and NICE has either rejected or restricted their use in the NHS on the grounds that they are not cost-effective. In effect NICE is saying that the money could and should be better used to treat other patients and deliver even greater benefits to the community overall.

[BridgeTroll]

But wait... there is more...

http://en.wikipedia.org/wiki/Quality-adjusted_life_year

Quality-adjusted life year
From Wikipedia, the free encyclopedia

The quality-adjusted life year (QALY) is a measure of disease burden, including both the quality and the quantity of life lived[1][2][3]. It is used in assessing the value for money of a medical intervention. The QALY model requires utility independent, risk neutral, and constant proportional tradeoff behaviour[4].

The QALY is based on the number of years of life that would be added by the intervention. Each year in perfect health is assigned the value of 1.0 down to a value of 0.0 for death. If the extra years would not be lived in full health, for example if the patient would lose a limb, or be blind or be confined to a wheelchair, then the extra life-years are given a value between 0 and 1 to account for this.

[edit] Use
The QALY is used in cost-utility analysis to calculate the ratio of cost to QALYs saved for a particular health care intervention. This is then used to allocate healthcare resources, with an intervention with a lower cost to QALY saved ratio being preferred over an intervention with a higher ratio. This method is controversial because it means that some people will not receive treatment as it is calculated that cost of the intervention is not warranted by the benefit to their quality of life. However, its supporters argue that since health care resources are inevitably limited, this method enables them to be allocated in the way that is most beneficial to society.


[edit] Meaning
The meaning and usefulness of the QALY is debated[5][6][7]. Perfect health is hard, if not impossible, to define. Some argue that there are health states worse than death, and that therefore there should be negative values possible on the health spectrum (indeed, some health economists have incorporated negative values into calculations). Determining the level of health depends on measures that some argue place disproportionate importance on physical pain or disability over mental health. The effects of a patient's health on the quality of life of others (e.g. caregivers or family) do not figure into these calculations.


[edit] Weighting
The "weight" values between 0 and 1 are usually determined by methods such as:

Time-trade-off (TTO) - In this method, respondents are asked to choose between remaining in a state of ill health for a period of time, or being restored to perfect health but having a shorter life expectancy.
Standard gamble (SG) - In this method, respondents are asked to choose between remaining in a state of ill health for a period of time, or choosing a medical intervention which has a chance of either restoring them to perfect health, or killing them.
Visual analogue scale (VAS) - In this method, respondents are asked to rate a state of ill health on a scale from 0 to 100, with 0 representing death and 100 representing perfect health. This method has the advantage of being the easiest to ask, but is the most subjective.
Another way of determining the weight associated with a particular health state is to use standard descriptive systems such as the EuroQol Group's EQ-5D questionnaire, which categorises health states according to the following dimensions: mobility, self-care, usual activities (e.g. work, study, homework or leisure activities), pain/discomfort and anxiety/depression.

However, the weight assigned to a particular condition can vary greatly, depending on the population being surveyed. Those who do not suffer from the affliction in question will, on average, overestimate the detrimental effect on quality of life, compared to those who are afflicted.

[BridgeTroll]

Faye?  Crys?  Comments?

[CrysG]

NICE publishes clinical appraisals of whether particular treatments should be considered worthwhile by the NHS. These appraisals are based primarily on cost-effectiveness.

So you hate the fact that treatments are "rationed" out that the decisions are based off of cost-effectiveness?

The insurance industry in the United States has a single purpose, to provide a stream of profits to shareholders who own the stock of healthcare companies. Guaranteeing the healthcare needs of the American people is not even an afterthought.  Our private, for-profit insurance industry is a huge, sophisticated and dangerous denial machine.

http://www.guaranteedhealthcare.org/blog/nyceve/2008/07/31/inside-insurance-industry-denial-machine

[BridgeTroll]

Blog entries titled "inside-insurance-industry-denial-machine" are not exactly going to convince anyone of anything...

[JeffreyS]

Don't you ration health care by having an HMO manage it?  Isn't that the stated purpose of Health maintenance organization?

an HMO covers only care rendered by those doctors and other professionals who have agreed to treat patients in accordance with the HMO's guidelines and restrictions in exchange for a steady stream of customers.

http://en.wikipedia.org/wiki/Health_maintenance_organization

[BridgeTroll]

So when the government strapped doctor comes to you with a sad look on his face and tells you your loved one can be saved but will not because it is not within the governments guidlines... you will be fine with that??  You would shake the doctors hand and say "thanks doc... it is good to know my loved ones sacrifice will ensure everybody gets their flu shot"??

Your predictable rebuttal will be that the insurance company also does this.  Yes but... I can chose coverage, I can choose insurers, I can choose how much I pay.

All choice is removed when the government steps in.

[CrysG]

Fine,

http://www.medicalnewstoday.com/articles/52604.php
http://www.cnn.com/2008/HEALTH/12/11/health.insurance.bad.economy/index.html+
http://blogs.usatoday.com/oped/2008/01/individual-heal.html
http://www.nytimes.com/2008/04/11/opinion/11krugman.html

If you have a problem with CNN, USA Today and the NY Times, let me know.

[CrysG]

So when the government strapped doctor comes to you with a sad look on his face and tells you your loved one can be saved but will not because it is not within the governments

Where do you find that single payer health care says you can't have assess to life saving medicine or treatment? So your wife wont get her boob implants so everyone can have a flu shot......I mean she's gonna DIE without those boobs.

Yes but... I can chose coverage, I can choose insurers, I can choose how much I pay.

Really you can MAKE insurance companies cover you? You can tell them how much to charge you?

There are story after story out there where people can't find insurance companies to insure them. I've posted them before. Just because YOU can find doesn't mean they will cover everyone.

There is more evidence than ever that not having health care insurance can cost you your life. I was pretty struck by a report this morning showing that cancer patients were 1.6 times more likely to die in five years if they did not have insurance. (Watch Video)

And, here is something even more striking: A patient with grade 2 cancer has a 90 percent survival rate at five years if the patient is insured. A patient with grade 1 cancer (a better stage to have) has an 80 percent survival rate if the patient is not insured. Yes, you read that right. According to new data from the American Cancer Society, being uninsured makes you less likely to survive, even if you start with a lower-grade cancer.

There are more insurance issues raised in the study, and many of them have to do with lack of access to care. For instance, 86 percent of insured women get pap smears, compared to only 68 percent of uninsured women. And, to make matters worse, if you do develop cancer, it is often difficult to get insurance because you now have a pre-existing condition. In fact, health care proposals released by presidential candidates Rudy Giuliani, John McCain and Fred Thompson have few provisions for people to obtain insurance if they already have a medical condition. That is all the more ironic, given Mayor Giuliani's history of prostate cancer, Sen. McCain's history of melanoma and Sen. Thompson's history of lymphoma.

http://www.cnn.com/HEALTH/blogs/paging.dr.gupta/2007/12/pre-existing-conditions-preclude-you.html

[BridgeTroll]

If you have a problem with CNN, USA Today and the NY Times, let me know. 

No... I am good with them.  You seem a bit touchy... or stressed.  Everything OK?

[JeffreyS]

So when the government strapped doctor comes to you with a sad look on his face and tells you your loved one can be saved but will not because it is not within the governments guidlines... you will be fine with that??  You would shake the doctors hand and say "thanks doc... it is good to know my loved ones sacrifice will ensure everybody gets their flu shot"??

Your predictable rebuttal will be that the insurance company also does this.  Yes but... I can chose coverage, I can choose insurers, I can choose how much I pay.

All choice is removed when the government steps in.

A very reasonable fear.  You shouldn't be denied treatment because of  government underfunding or private profit considerations.  I guess I just hope the primary motivating factor of one system might be more on the side of saving my loved one.
I hope I am not being to naive.  The choice factor may be over stated by the fact that the insurance companies will always be better informed than the public about where cutting back may be dangerous.

[CrysG]

No... I am good with them.  You seem a bit touchy... or stressed.  Everything OK?

I'm good. I personally have health care, but at the moment I can think of at least 2 people who are either fighting with their insurance company to get them to pay for life saving treatment or who don't have health care because they are two rich to get on Medicare and two poor to afford independent health coverage.

[BridgeTroll]

It is a very reasonable fear if you read the first two posts in this thread.  It is the method the Brits have come up with to decide on treatments and their costs and when you may not get treated and how that decision is made.

[BridgeTroll]

I'm good. I personally have health care, but at the moment I can think of at least 2 people who are either fighting with their insurance company to get them to pay for life saving treatment or who don't have health care because they are two rich to get on Medicare and two poor to afford independent health coverage.

I am glad to hear that Crys.  No doubt this can be a personal and emotional topic.  What I remind myself is the person I am debating simply has another viewpoint on the solutions to these problems.  The debate is healthy if we remember that.  I respect yours and Fayes opinions here because they are well thought out and frankly I agree with some of your solutions and we most definitely agree on most of the problems.  We all know...

at least 2 people who are either fighting with their insurance company to get them to pay for life saving treatment or who don't have health care because they are two rich to get on Medicare and two poor to afford independent health coverage.

The system needs reform for exactly the reason above in quotes... We should be able to do this without hating the other side.

[brapt]

Hello all.

Not to derail, but I couldn't help but find the British bureaucracy's acronym an interesting choice.

It was set up as the National Institute for Clinical Excellence in 1999, and on 1 April 2005 joined with the Health Development Agency to become the new National Institute for Health and Clinical Excellence (still abbreviated as NICE).

Has anyone read C.S. Lewis' "That Hideous Strength (ca. 1945)?" 

his final novel in the Space Trilogy is set in 1940s England "vaguely after the war" in the small university town of Edgestowe, in which the National Institute of Coordinated Experiments (the "N.I.C.E."), a fictional scientific agency secretly inspired and directed by fallen eldila, attempts to alter the true nature of mankind through an exploitation of its members' pride and greed. Its goal is nothing less than the conquest of human nature, making true man a lost memory.

http://en.wikipedia.org/wiki/That_Hideous_Strength

Ah well, off-topic I know, but it was the first thing that came to mind when I saw that title!