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EDITORIALS: R E Ferner and Sarah E McDowell A model for NICE in the US BMJ 2009; 338: b2221 [Full text]

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Cost-effectiveness analysis represents overt rationing

Adam M Ali   (13 June 2009)

Global comparison is even better

Michael Forrest   (15 June 2009)

Cost-effectiveness analysis represents overt rationing 13 June 2009
Adam M Ali, Frank Knox Fellow, Harvard University MA02138 Send response to journal: Re: Cost-effectiveness analysis represents overt rationing	It is important to realise that the term 'cost-effectiveness' is political dynamite in the US; 'rationing' is a dirty word that to many Americans conjures up images of socialist medicine and big government at its worst. It is no mistake that President Obama's healthcare plan goes only so far as to state the need for 'comparative' effectiveness without mentioning the word cost in the same sentence (1)- he is scared of what might happen if people perceive him to be limiting choice. But can we really blame him? When President Clinton attempted to introduce a national health insurance program in 1993, the insurance industry mounted a potent media campaign against it to protect their financial interests: the 'Harry and Louise' television commercials played a major role in derailing the Clinton plan by spreading fear amongst the American people that the choice they so dearly value would be taken away from them (2). One of the advertisements featured the couple speaking as follows: Background voice: Things are changing, and not all for the better. The government may force us to pick from a few healthcare plans designed by government bureaucrats Louise: Having choices we don't like is no choice at all Harry: They choose Louise: We lose The insurance industry knew exactly which buttons to press to stop the Clinton plan dead in its tracks. I sincerely hope that President Obama can implement the use of cost-effectiveness analysis as it is so desperately needed to control spiralling costs - but overcoming opposition from those with vested interests in the status quo and persuading the American people to allow central government to ration resources will be no easy task. (1)Obama '08, Barack Obama and Joe Biden's plan to lower health care costs and ensure affordable, accessible health coverage for all. http://www.barackobama.com/pdf/issues/HealthCareFullPlan.pdf (2)Harry and Louise Go to Washington: Political Advertising and Health Care Reform. Journal of Health Politics, Policy and Law 1996; 21(1):35-68. Competing interests: None declared
Global comparison is even better 15 June 2009
Michael Forrest, GP Karis Medical Centre, Waterworks Road, Edgbaston, Birmingham B16 9AL Send response to journal: Re: Global comparison is even better	Hardin was originally concerned with environmental conflicts, but Ferner and Mcdowell use his model to illustrate the tension between the vested interests of the Pharmaceutical Industry and concerned clinicians and patients on the one hand and NHS rationing on the other. The real "tragedy of the commons" in healthcare resources however is the enormous disparity between the rich North and the poor South. Perhaps the "tragic stories ensuing from unmet need elsewhere" should refer to the differences in cost and benefit between any expensive therapy in the UK and, shall we say, oral rehydration solution in sub-Saharan Africa. The word marginal would not appear in the ratios and the analysis would put the debate into a more global context. The retort "but it's not my problem" may well be even louder than the same complaint about NICE, but at least there would be more eQALYty in adjusted life years comparisons. It's time for the profession to worry more about the bigger picture of disparity in global health. Competing interests: Trustee ActionAid UK