A model for NICE in the US
BMJ 2009; 338 doi: https://doi.org/10.1136/bmj.b2221 (Published 03 June 2009) Cite this as: BMJ 2009;338:b2221
All rapid responses
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
Competing interests: No competing interests
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
Competing interests: No competing interests