Rationing Health Care - it's a lie!

[Ziggurat]

The price is part of the application, I guess

Is the application ever denied because of price? If not, then there is no negotiation, even implicitly. If so, then you are walking away from some drugs. That may be the right thing to do, but that doesn't contradict anything I've been arguing. Quite the reverse.

 

[BeAChooser]

On another thread a poster (possibly BaC but I'm not sure) declared that it was impossible for the USA to negotiate any price reductions for patented drugs, because to do that you'd have to be prepared to refuse to pay at the higher price.

Nope, wasn't me.

BaC was saying that the imperative is on the purchaser to buy, so the provider can just choose to charge what he likes.

Nope, wasn't me. I really wish you wouldn't bring my name into threads unless you really are sure I said something.

I've had enough, recently, of people repeatedly claiming I took a certain position when I did no such thing.

 

[ddt]

Is the application ever denied because of price?

I don't know, I'll try to look into that.

If not, then there is no negotiation, even implicitly. If so, then you are walking away from some drugs. That may be the right thing to do, but that doesn't contradict anything I've been arguing. Quite the reverse.

I don't agree with that. There is an implicit negotiation: if you come with a me-too, don't make it more expensive than the existing ones. The pharma companies know that before they apply, so they would be awfully stupid to even try that. So no, absence of a denial pure on price is no evidence of lack of negotiation.

There are certainly cases where a drug was denied because it was more expensive and it wasn't shown adequately that it was better than existing ones.

 

[Fiona]

@kellyb

http://www.nhs.uk/Livewell/sexualhe...px?WT.srch=1&gclid=CKHIkZGioZwCFYYU4wodhFESdw

 

[Corsair 115]

In all seriousness, you'd think that our current treaties would prohibit this kind of thing so that it couldn't escalate.

The U.S. has demonstrated its willingness to ignore its treaty obligations whenever domestic political concerns make it expedient to do so. See: NAFTA and Canadian softwood lumber for one example.

 

[Ziggurat]

So what drugs are covered by insurance here that aren't covered in countries with UHC?

I can give a few examples of drugs that are not covered by some UHC's (I wouldn't expect all UHC's to have the same list of non-covered drugs). For example, Lapatinib (which can extend the life of women with terminal breast cancer) is not approved by NICE, and so is not covered by the NHS. I do not know its status with US health insurance providers, nor am I sure what that would demonstrate, because if insurers here are not covering it, then they're doing exactly what I said the US government would have to do in order to negotiate lower prices: they're walking away from some drugs.

 

[Ziggurat]

I don't agree with that. There is an implicit negotiation: if you come with a me-too, don't make it more expensive than the existing ones.

Exactly: you're walking away from the me-too when it's more expensive. Like I said, that may be the right thing to do, but you're still walking away from some drugs in order to get lower prices.

 

[Delscottio]

I can give a few examples of drugs that are not covered by some UHC's (I wouldn't expect all UHC's to have the same list of non-covered drugs). For example, Lapatinib (which can extend the life of women with terminal breast cancer) is not approved by NICE, and so is not covered by the NHS.

Do you mean this one? http://nhs.medguides.medicines.org....e=Lapatinib+ditosylate+monohydrate&use=cancer

Be careful, the vast majority of drugs are approved for NHS but the circumstance to use them is where a lot of the problems arise.

 

[DC]

Covered since 1. Aug. 2007

http://www.sprechzimmer.ch/include_php/previewdoc.php?file_id=4107

mmh took 2 months from aproval to coverage.

 

[ddt]

Exactly: you're walking away from the me-too when it's more expensive. Like I said, that may be the right thing to do, but you're still walking away from some drugs in order to get lower prices.

OK. I think we've been talking past each other on this point, and we actually agree. The "walking away" part happens there implicitly. For some drugs, the pharma company will decide to apply at a lower price point, for others, it won't even bother to apply.

And as a followup to that, I'd argue: the way the process works, those drugs that are not approved for reimbursement, are not needed anyway.

 

[Rolfe]

Nope, wasn't me.

Nope, wasn't me. I really wish you wouldn't bring my name into threads unless you really are sure I said something.

I've had enough, recently, of people repeatedly claiming I took a certain position when I did no such thing.

Very sorry. I did say I wasn't sure. Ziggurat has ownerd up.

Rolfe.

 

[Newtons Bit]

RATIONING ARGUMENT MAKES THE BBC

The Jeremy Vine show in BBC Radio 2 today picked up on the US media adverts claiming nasty things about the NHS, and decided to go to town on it. They invited a representative of the lobby group who made the advert claiming the maximum spend on drugs was $22k or thereby, and a professor of clinical medicine from Edinburgh University.

She completely trashed his "facts", speaking authoritively to issues around NICE recommendations, target values for treatment drugs, and access to things like dialysis.

He, in turn, was asked to respond. And you know what? He changed the subject. Instead of focusing on the points she had refuted in the argument, he tried to argue that the US system was based on "freedom" whilst the HNS was based on "fairness".

Really, I'm not making this up. I'll see if I can find a link on iPlayer, but I don't think our North American cousins can use iPlayer - can they? Some sort of copyright/software issue?

ETA: Ah, there it is. The piece starts around the 1hr mark, just after the 1pm news. I only caught 15 minutes of it myself, as I was going into a meeting.

http://www.bbc.co.uk/iplayer/episode/b00m0208/Jeremy_Vine_13_08_2009/

Us NA folks can use iPlayer, if we go through a proxy. Proxies are slooooow. Ask me how I know.

I think it's illegal though.

 

[Ziggurat]

Be careful, the vast majority of drugs are approved for NHS but the circumstance to use them is where a lot of the problems arise.

Which means the NHS isn't walking away from the drug completely, but only in some cases. The concept is still the same: they're forgoing purchases because of the price, which is the only way to get leverage to lower prices.

 

[Newtons Bit]

If only......

(sigh)

Right, mandatory fee scales were abolished back in the late 80s, when I was still a student, as the EU ruled them to be a restrictive practice. Recommended fee scales were then issued for a while, but the EU spotted this blatant fiddle and stopped it, not least by lodging a huge fine against the Belgians.

Fees are therefore now calculated on a straightforward cost-resource basis, usually on a competitive tender process. To put this in perspective, housing can drop as low as 3 or 4% (madness), hotels sit around the 6 or 7% mark, and high end conservation projects sit around the 8 to 10% mark.

The profit margins are pretty constant across all these sample sectors, the higher % fees being a reflection on the time/complexity.

Traditionally the design team are appointed separately in the UK and Europe, as it makes liability issues more straightforward. "One stop shop" appointments are becoming more common, particularly at the early stages. Don't even start me on design and build contracts.

Now, my practice were one of two architects for the upgrading of a very large hotel where the Open was just hosted. Contract value £28.5m. We provided the specialist heritage advice (heck, tower blocks to conservation, there you go, it's a funny old game) and we were on a direct appointment from the client. The lead architect, services, and structural engineers were appointed directly and separately.

Does that clarify matters?

Those dern architects always tell me that we always get 6%! I think they're skimping out on us.

Please us common sense here, some buildings are even lower than 3% such as warehouses (they're sometimes just a flat fee regardless of size).

But the point I was getting at is that everyone who responds to a request for proposal gets the same rate because the owner has already decided the construction budget. The person with the best design gets the job. Design-build works a bit differently.

 

[Rolfe]

The theory that "negotiating down pharma prices means that the buyer sometimes says 'no', which would anger Americans" is plausible. But it's just a theory, and we're not in a position where we're at the mercy of competing guesses about how things actually pan out. Every other developed country has UHC, so we should be able to do some sort of actual compare and contrast here.

I honestly don't know. What I think is that newer, expensive drugs will find some takers in the USA before they're approved for use in Britain. People with 5-star insurance coverage, or maybe even people who simply have a lot of money, will get them. However, they won't be universally available at that stage as far as I understand it.

However, once the drug has received approval for NHS use, then it is immediately available for everybody who needs it, and nobody

Is birth control covered under UHC? (it's often not under private insurance in the US.)

I saw Fiona's link, but the answer is yes. So "yes" that as far as I know it's even exempt from the prescription tax in countries that still have it (we're looking at you, England....)

It's an old joke that all but one of the original manifesto pledges made when the Monster Raving Loony party was launched in (I think) the 1960s have actually been delivered. Free birth control was one of them. (The outstanding one is legalising pot.)

Rolfe.

 

[Ziggurat]

And as a followup to that, I'd argue: the way the process works, those drugs that are not approved for reimbursement, are not needed anyway.

That's probably true, but if it's really a me-too without advantages, then many doctors would keep prescribing the old stuff even if the new stuff were approved. Worth doing? Sure. A major cost reduction? Probably not.

 

[Darat]

Which means the NHS isn't walking away from the drug completely, but only in some cases. The concept is still the same: they're forgoing purchases because of the price, which is the only way to get leverage to lower prices.

That is simplifying things to a unrealistic extreme, negotiating a supply contract is rarely, if ever, just about the price.,

 

[Delscottio]

Which means the NHS isn't walking away from the drug completely, but only in some cases. The concept is still the same: they're forgoing purchases because of the price, which is the only way to get leverage to lower prices.

My understanding is the leverage is used on the generic drugs that that company produces.

A case of fair enough charge your £100k on this wonder drug but we'll buy our £1m worth of paracetamol from your competitor. Its not in the drug companies interest to substantially over charge such a massive customer.

There will be other saving for the drug companies in transportation, invoicing etc.

 

[Darat]

I am pretty sure this year one of the high-ticket drugs was approved by NICE after the manufacturer agreed to pay for half the cost of the first round of treatment. I thought I'd read about it on the BBC news site but I can't find it. Does it strike a bell with anyone else?

ETA: Found it!

This is an example of the type of complex negotiation that actually happens: http://info.cancerresearchuk.org/news/archive/newsarchive/2009/june/19234946

 

[ddt]

That's probably true, but if it's really a me-too without advantages, then many doctors would keep prescribing the old stuff even if the new stuff were approved. Worth doing? Sure. A major cost reduction? Probably not.

The pharma companies quite aggressively promote their new drugs with doctors. Their marketeers who visit the doctors are not hindered by actual medicinal knowledge (rather not, because then they could be caught lying), and skirt on the border (and sometimes over) of what is permissible.