News Cut: August 25, 2009 Archive

The health care debate: Marginal treatments

Posted at 2:00 PM on August 25, 2009 by Bob Collins (11 Comments)
Filed under: Health, Politics

Sen. John McCain is back on the stump with a "town meeting" style event for health care today.

"You know in England, the NICE (National Institute for Health and Clinical Excellence) has denied treatment for women with breast cancer, and people with Alzheimer's, and denied life-saving drugs for people with MS," the former presidential candidate said to a group of mostly senior citizens, the one demographic he won in last year's election.

True?

Apparently so. And it comes directly from a briefing paper prepared by the conservative Heritage Foundation, which said:

* NICE restricted access to two drugs for Age-Related Macular Degeneration, Britain's leading cause of blindness.[6] The first drug, Macugen, was completely blocked, while the second, Lucentis, was limited to the approximately one in five disease sufferers who have a specific type of the disorder.[7] Even then, Lucentis was restricted to patients with that type of the disorder in both eyes--and could only be used in the less-diseased eye. In the words of Tom Bremridge, chief executive of the Macular Disease Society, "allowing one eye to go blind before treating the second eye is cruel and totally unacceptable." Winfried Amoaku of the Royal College of Ophthalmologists explained, "There are differences in action between these two drugs, which may be important in individual cases, and so we do not wish to be limited in our treatment options in this way."

* NICE limited several Alzheimer's drugs to use in patients whose disease had advanced from early to middle-stage. Even though doctors argued that starting treatment at the onset of dementia would be most effective in slowing the progression of the disease,[8] NICE decided that patients would have to wait until they became sick enough for the treatments to meet the cost-effectiveness threshold. A charity has taken legal action, accusing NICE of "ignoring totally the proven benefits of the drugs for careers of those with mild symptoms, and grossly underestimating the savings they bring to the state by enabling suffers to remain in their own homes longer. [The charity] accused NICE of implying careers are far better off when the condition of their sick relative deteriorates so much that they are forced to move into a residential home."[9]

* NICE blocked access to Glivec, a leukemia treatment. Ann Tittley, a 55-year-old patient, was being treated for breast cancer when she was diagnosed with leukemia. After realizing she would be denied access to Glivec even though her physician had recommended she start it immediately, Ms. Tittley wrote a letter to then-Prime Minister Tony Blair. "Glivec was my lifeline, at least it would give me a chance of beating this disease," wrote Ms. Tittley. "Life is precious.... I appreciate that cost is important, but to deny patients this potentially life-saving treatment on this basis is totally unforgivable and criminal."[10]

In a June article, the Economist noted the concerns and suggested, however, there are provisions which could prevent them in a reformed health care system:

In America, the drugs and devices lobbies are violently opposed to a NICE-style agency that could issue mandatory rulings. They paint a scary picture of Americans being denied access to life-saving new drugs by faceless bureaucrats. In Britain NICE has come under fire for rulings that limited access to expensive drugs for Alzheimer's and cancer on the NHS. America could get around this problem by requiring and perhaps even funding studies, but leaving insurers and individuals to decide whether to pay for treatments.

As with many aspects of the health care debate, there's more to the story. Aricept is the drug NICE originally kept off its formulary, according to the New York Times. It costs about $2,200 a year and some Medicare drug plans pay for it; some don't, says The Times' Caring and Coping blog.

Daniel Callahan, a bioethicist at the Hastings Center, says the drug -- and several others that are linked to the anecdotes above, can slow the progression of a disease, but only for a short time and have only marginal benefits given their cost. It's a question, he says, Americans don't want to ask or discuss.

The most generic way this is done is to declare that life is priceless and even to pose such a question is immoral; and so also with the idea of rationing beneficial treatments. Considerations of cost should simply have no place in our reform calculus.

But there are more subtle ways that cost are sidelined in the reform debate. One of them is the powerful role of the pharmaceutical industry, also taken up in the New Old Age. By treating any consideration of cost as a threat to innovation, both the profit motive is protected (patents run out), and the American romance with endless medical progress is pandered to.

At the end of the debate where McCain traveled today, each side -- proponents and opponents -- can approach the same issue with two different questions.

(1) Why should the government tell me what drugs I can have when it should be my choice?

- or -

(2) Why should taxpayers -- or the other members of your insurance pool -- pay for a drug for you that has little value?

Pick your poison.

(AP Photo/Matt York)

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H1N1's big numbers

Posted at 7:00 PM on August 25, 2009 by Bob Collins (2 Comments)
Filed under: Health

After the hype surrounding H1N1 flu last April, and the resulting less-than-disastrous result ("only" 522 people have died), the President's Council of Advisors on Science and Technology isn't backing off from the big numbers. A report says that up to 90,000 people may die.

It's not that the H1N1 flu will be more severe that a typical flu-season strain, it's that more people will get it and, thus, more people will die. Up to half the population of the U.S. will get H1N1. There also isn't the immunity to this strain of flu.

During an online "chat" with Amy Garcia of the National Association of School Nurses today, a questioner from Minneapolis on the Washington Post site asked if the "concern that we just don't know how it will react, as compared to the flu that we usually get every year? Or is it something more than that?"

This strain of H1N1 flu is novel, meaning new. So it spreads easily because people have not been exposed and do not have antibodies to it. This strain of H1N1 concerns me for several of reasons:

1. It disproportionately impacts children and pregnant women.

2. There seems to be a higher incidence of pneumonia, possibly because this virus replicates deep inside the lung.

3. It spreads very easily and quickly. My school nurse friends who have witnessed outbreaks describe large numbers of children getting very sick, very quickly.

4. The H1N1 virus may mutate to be more deadly, and still very contagious.

The experts issue the same recommendations to people they've been issuing since last April: Wash your hands regularly, don't cough in someone's face, and stay home when you're sick.

That last item is the big nut in all of this. People who don't have any sick time, tend not to take days off regardless of their medical woes and the threat to the rest of us. So the same experts are asking employers to "be flexible," another way of saying "don't penalize them for staying home."

After last spring's build-up and resulting backlash, who's left who's still listening to the warnings and advice?

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