Rationing Health Care - it's a lie!

[kellyb]

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.

It's listed as a "restricted" drug.
https://www.bcbsnd.com/docs/restricted.pdf

Where's the American outrage you're predicting should exist? Or do you think the outrage would only manifest if it was a public institution doing the same thing?

 

[kellyb]

In which case my employer will bring their business elsewhere. Dropping customers isn't a winning strategy in the market, you know.



By telling them that I am unsatisfied, and want something done. They are sensitive to employee satisfaction.

Dropping unprofitable customers is actually a smart move for an insurance company.
And on point #2, you are unusually fortunate, you know.

 

[Architect]

No, I've been arguing that countries that set price controls screw over the USA (and other countries who don't have socialized medicine) who don't have price controls. That's what I've been arguing the whole time. It's not fair to the people who live in the USA.

Mate, we're not talking about price controls. We're talking about your healthcare provider being able to negotiate a price.

I mean, seriously, you're not suggesting that pharma regularly sells to UHC countries at a loss, are you?

I like it when new medications come online. I don't mind a company making an 8% rate of return for developing their new and awesome innovations. I would definitely be willing to pay a bit more. I don't mind paying someone to develop and create awesome new things. Why? Because new and awesome things improve our lives. Their ability to make a rate of return is the reason why they innovate things that improve our lives.

Indeed. No-one's arguing.

I do something similar for a living. I create designs that enable other people to construct homes and hospitals and schools. My particular profession owns the right to those designs for quite literally forever (life + 99 years or whatever obscene amount it is now) But why should I charge at all for these designs? The things my profession creates are life-saving (they protect people in earthquakes and hurricanes), they're absolutely necessary for our current society to function the way it does. Should I not get paid for my work?

Unless US law is markedly different from the rest of the world, or you're patenting new structural systems, then it's actually a copyright issue and you'd have to show that someone had massively copied your work. It doesn't really work that way, in practice. Designs develop incrementally. Otherwise you Yanks would have been paying Mies' estate a ruddy fortune.

The argument that I think you're trying to make is that I shouldn't be able to charge what I feel is a reasonable amount for the new and awesome innovations I create solely because they protect peoples lives. If the real-world really worked that way I would quit my job (since I wouldn't be making anything doing it) and spend my days laughing at those who took away my ability to earn a living as they tried to construct new buildings in seismic regions.

Seismic research is often funded by government agencies and carried out by universities, IIRC, although I'd have to look into that. Arup used to get a bit of that kind of thing too. But I can't think of too much of the private sector doing it.

In the end, new innovation depends upon people getting something for their work. Some people are okay with the acclaim from their peers. The rest of us prefer cold hard cash.

Uh-huh. No-one arguing there.

The entire sub-argument of an argument I made much earlier is: The USA ends up paying more than its fair share of the profit and R&D of new drugs. And I think that this is wrong.

evidence?

I also think price fixing by countries with socialized medicine is wrong and is one of the reasons why Americans pay more for healthcare. No one has disagreed with this point. But I've been bombarded by people exclaiming that, "if only the USA price fixed too, then everyone would be happy!". I think that would stifle innovation.

No-one's talking about price fixing. We're still talking about bargaining.

 

[Ziggurat]

Out of interest is there a maximum your insurer will pay out?

No, although there are some restrictions (to go above a certain amount, I must receive care from their network of providers).

ETA: Or you lose your job?

If I lose my job, I can extend my coverage with COBRA for 18 months (longer if I get disabled). I will eventually need to find new insurance, but as long as I haven't let my coverage lapse, this isn't hard to do. Where people generally get into trouble is when they let their coverage lapse.

 

[Ziggurat]

Dropping unprofitable customers is actually a smart move for an insurance company.

Not really, because it drives away profitable customers too by decreasing the value of the policy you offer.

 

[Ziggurat]

Where's the American outrage you're predicting should exist?

Right here, on this forum, from people complaining about evil insurance companies.

Or do you think the outrage would only manifest if it was a public institution doing the same thing?

I think it would manifest to a greater degree, yes.

 

[3point14]

Not really, because it drives away profitable customers too by decreasing the value of the policy you offer.

How did you pick your insurance company? Which statistics did you study? Can we see them?

 

[Ziggurat]

How did you pick your insurance company? Which statistics did you study? Can we see them?

I picked my plan from among the offerings based on the benefits it provided. And no, you can't see that because I choose to keep my employment private. I don't need to worry about my company being dropped, that's HR's job to figure out.

 

[Delscottio]

No, although there are some restrictions (to go above a certain amount, I must receive care from their network of providers).

Excellent to hear.

If I lose my job, I can extend my coverage with COBRA for 18 months (longer if I get disabled). I will eventually need to find new insurance, but as long as I haven't let my coverage lapse, this isn't hard to do. Where people generally get into trouble is when they let their coverage lapse.

Is the coverage at the same cost to you for those 18 months, will that insurer then ask about previous conditions etc?

 

[Rolfe]

I'm just trying to get this straight.

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.

Immediately, we find that's not the case.

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

Try this link. http://nhs.medguides.medicines.org.uk/nhs/medicine.aspx?name=Tyverb&use=Breast cancers&preparation=1

"Your health, your choices" it says at the top of that web page.

The Swiss rebuttal took a little longer.

Covered since 1. Aug. 2007

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

mmh took 2 months from aproval to coverage.

Now to be fair, Ziggurat said he didn't know if it was available in the US system or not. It is....

Sort of....

It's listed as a "restricted" drug.
https://www.bcbsnd.com/docs/restricted.pdf

The two universal healthcare systems simply say the drug is available. The insurance company has a pile of ifs and buts. Limited dispensing amounts. Prior approval. Restricted use.

Well, I know it's not that simple. However, which of us seems on this evidence to have a bureaucrat standing between us and our doctors?

Rolfe.

 

[3point14]

I picked my plan from among the offerings based on the benefits it provided. And no, you can't see that because I choose to keep my employment private. I don't need to worry about my company being dropped, that's HR's job to figure out.

Just on the benefits? Not on any other statistics?

 

[Ziggurat]

Immediately, we find that's not the case.

That page says nothing about availability, only its existence.

"Your health, your choices" it says at the top of that web page.

And a generic web page header indicates that it's available for women with terminal breast cancer? No, I do not think so.

The Swiss rebuttal took a little longer.

I made no claims about its availability in Switzerland. In fact, I rather explicitly stated that I would expect availability of any given drug to vary from system to system.

Now to be fair, Ziggurat said he didn't know if it was available in the US system or not. It is....

Sort of....

It is available. Not without restriction, but your links do not demonstrate it is available without restrictions in the UK either.

The two universal healthcare systems simply say the drug is available.

But not under what conditions.

Well, I know it's not that simple.

Then don't pretend it is.

However, which of us seems on this evidence to have a bureaucrat standing between us and our doctors?

Really, Rolfe, you should know better than to think that the web link given above is any indicator of how easily available that drug is within the UK. It is not. All that page does is list what the drug is, nothing more. So, is the drug available in the UK without restriction?

http://www.cancerbackup.org.uk/Treatments/Biologicaltherapies/Cancergrowthinhibitors/Lapatinib

"Although Lapatinib is licensed and can be prescribed in the UK, it is currently being assessed by the National Institute for Health and Clinical Excellence (NICE) and the Scottish Medicines Consortium (SMC) for use in the NHS. NICE and the SMC give advice on which new drugs or treatments should be available. As a result Lapatinib may not be widely available on the NHS."

And we've found our bureaucrats standing between you and your doctor, and they're called NICE. So let's see what NICE says:

http://guidance.nice.org.uk/TA/Wave13/1

And what's NICE's current ruling?
"Lapatinib (in combination with capecitabine), within its licensed indication, is not recommended for the routine treatment of women with previously treated advanced or metastatic breast cancer whose tumours overexpress HER2, except in the context of clinical trials."
Which means its availability under the NHS is restricted.

 

[Ziggurat]

Just on the benefits? Not on any other statistics?

That's the primary one, since it's the primary distinguisher between what I chose and other options. Customer satisfaction surveys are easy to find and compare. Statistics like how often they drop a company are irrelevant to me, because that's HR's problem, not mine.

 

[3point14]

That's the primary one, since it's the primary distinguisher between what I chose and other options. Customer satisfaction surveys are easy to find and compare. Statistics like how often they drop a company are irrelevant to me, because that's HR's problem, not mine.

And if you were self employed? How would you assess things then?

Or do you not consider that because you're not in that position?

 

[Rolfe]

OK, fair enough on that one. As I said, I expect that some people in the USA will get a new expensive drug earlier, but when the NHS approval processes are complete, then everyone who needs it will get it.

Rolfe.

 

[Fiona]

Not a doctor and I do not understand this completely but for what it is worth this is the report from the Scottish Medicines consortium on the application for approval of Lapatinib. This was decided before the final NICE determination in March and the subsequent appeal to that body which was upheld in July 2009 (second link)

http://www.scottishmedicines.org.uk/smc/files/lapatinib Tyverb FINAL January 2009 for website.pdf

http://pharmatimes.co.uk/Forums/forums/t/4274.aspx

So far as I can determine the application was based on the submission from GSK resting heavily on one study which is outlined in the report

The main findings were that there were no significant differences in survival between those patients who received liptanib together with capecitabine (Xeloda) compared to those who got capecitabine only. However the firm chose time to progression as the primary indicator and there were significant benefits on this measure. The study notes that

From the study, the addition of lapatinib to capecitabine increased median TTP by 8.5 weeks compared with capecitabine monotherapy

Although more favourable results were seen for the lapatinib plus capecitabine arm versus capecitabine monotherapy in terms of quality of life measures, these differences were not statistically significant.

Capecitabine is recommended for use in Scotland by oncologists with appropriate expertise in treating locally advanced/metastatic breast cancer

and that decision was reached in 2003. According to this article it costs £2478 for 24 weeks of treatment compared to £11,634 for that combined with liptanib. The company has since disputed these costs and has presented fresh evidence to NICE (see second link)

It seems to me that these are complicated issues but it does look as though this is an evidence-based approach. It is unpleasant to think that cost/benefit is applied but I do not think any system can avoid this. I like the fact that this information is readily available.

I also note that the original NICE decision in March was debated in parliament which tends to reinforce the point made earlier that such decisions are subjected to a lot of scrutiny (and pressure). In this case the end of life criteria were altered to make patient access easier (ie raise the allowable cost) after much public discussion.

Is the same type of information available for the US ?

 

[ddt]

A US critic was brave enough to appear. When her turn came, what she actually came out with was the nonsense about the USA bankrolling drug development costs. Since the discussion had until that point been about the death panels and pulling the plug on grandma, Krishnan was a bit floored.

While it's obviously not relevant to that discussion, there may actually be truth in the matter that the USA bankrolls more drug development costs.

Marcia Angell in "The Truth about Drug Companies":

Since the United States is the major profit center, it is simply good public relations for drug companies to pass themselves off as American, whether they are or not. It is true, however, that some of the European companies are now locating their R&D operations in the United States. They claim the reason for this is that we don't regulate prices, as does much of the rest of the world. But more likely it is that they want to feed on the unparalleled research output of American universities and the NIH. In other words, it's not private enterprise that draws them here but the very opposite—our publicly sponsored research enterprise.

Of course, this has nothing to do with the proposed health care reform. The USA sponsors drug development through its universities and through NSF/NIH, and that's money that's totally outside of the health care budgets. Oh, and the rest of the world does so too in a similar vein, but likely to a lesser degree.

 

[Rolfe]

Hang on, don't tell Beerina that the US subsidises medical research! It will destroy his entire world-view!

Rolfe.

 

[ddt]

Hang on, don't tell Beerina that the US subsidises medical research! It will destroy his entire world-view!

Rolfe.

Should I edit my post?

 

[BeAChooser]

Originally Posted by Ziggurat
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.

It's listed as a "restricted" drug.

... snip url ...

Where's the American outrage you're predicting should exist? Or do you think the outrage would only manifest if it was a public institution doing the same thing?

Kelly, you are jumping to conclusions ... again. Restricted doesn't mean it's not approved by US insurance providers. What you linked doesn't say Blue Cross won't pay for it. Just that you need prior approval before they will.

This:

http://docs.google.com/gview?a=v&q=...pdf+Lapatinib+insurance+companies&hl=en&gl=us

shows that Cigna will cover Lapatinib as well for "treatment of advanced or metastatic breast cancer" ... as long as:

- Human Epidermal Receptor 2 (HER2) positive
- when used in combination with capecitabine (Xeloda)
- prior therapy includes an antracycline, a taxane, and trastuzumab

And those requirements appear to be the FDA approved indications for use of the drug. There doesn't appear to be a conspiracy by private insurers to keep this drug from patients.

Likewise, this:

http://74.125.155.132/search?q=cach....pdf+Lapatinib+aetna&cd=1&hl=en&ct=clnk&gl=us

and this:

http://www.aetna.com/products/rxmedicare/data/Medicare2009/ANEOPL2009/antineoplastics-oral.html

indicates that Lapatinib is approved and one of the most prescribed medications by Aetna.