No. What I actually hypothesized does in fact happen. That's already been discussed - there are questions of degree, but that it happens is actually beyond dispute. But I ignored most of your post because it was quite disconnected from what I actually said.
Are we still talking about how it's impossible to get a discount on list prices of drugs unless you're prepared to "walk away from the deal"? I think you're stretching your interpretation of what actually happens. The drug you named appeared still to be in the evaluation phase in both Britain and the USA. It was restricted in its availability in both countries.
I always conceded that the NHS takes time to evaluate new drugs for cost-effectiveness. This is especially true for drugs that are not likely to be curative. We're back to the "rationing" again, which is going to happen in any system. No common good pool, insurance or public, is going to pay out £50,000 for a 1 in 100 chance that a terminally ill cancer patient will live for an extra week. On the other hand, paying out £1,000 for an 80% chance of an extra six months is likely to be funded by even the most parsimonious.
Every system has to decide just where it draws the line between these extremes. The NHS does this by the QALY, which tries to put a figure on the cost-benefit equation. The USA doesn't seem to have quite such a standardised system, but it's still going to happen. Blank cheques aren't on the table. If you think the NHS is too restrictive, then you simply increase the amount you're prepared to pay per QALY - you can't, ever, say you'll pay any price for the most marginal benefit.
Now given that this process occurs in both countries, it's a bit disingenuous to look at the NHS alone and accuse it of "walking away from the deal" in this context. Indeed, for this class of drug, one way to get approved is to lower the price so that the cost per QALY comes in under the targets. However, experience shows that drugs that are self-evidently beneficial, and especially drugs that are curative, are not held in this part of the system for long. The arguments happen over things which confer small benefits in the first place. And they happen just the same in the USA, even if the sticking point may be a little higher.
This is really of peripheral relevance to the question of drug pricing in general. We're not getting all these good deals right across the board for all the basic staples of medical treatment just because manufacturers are frightened of NICE and the QALY. We're getting them by normal commercial negotiating procedures, just like I'm getting my £26,500 list price new car for £22,500 plus scrappage. Because the manufacturers have that sort of discount built into their pricing system, and
expect to offer that kind of price to their large customers.
Rolfe.
