Industry Voices: NICE tries to expand healthcare coverage

This week Senator Max Baucus released a blueprint to create a national health plan. A central feature of his proposal is something called the The Health Care Comparative Effectiveness Research. The Institute is modeled on Britain's National Institute for Health and Clinical Excellence (NICE) which was established to compare the relative value of medical technology. The Institute has enthusiastic support from advocates of government-run healthcare and the health insurance industry's lobby, America's Health Insurance Plans (AHIP). Both groups argue that the institute should compare treatments for the same disease, find which works best, chuck the one's that are less effective and use the savings to pay for expanded insurance coverage.

Baucus claims the Institute's decisions would not be binding. The problem is that voluntary decisions don't stay voluntary for long. NICE decisions were immediately adopted by Britain's National Health Service to determine what it would pay for and to further tighten the government's control over healthcare.

Comparative effectiveness advocates like the fact that NICE focuses on the value of care. Recently the group ruled that four drugs used to extend the life of people with stomach cancer "aren't effective enough to warrant their high cost and shouldn't be prescribed to new patients." NICE decided that the $39,000 the drugs would cost to keep people alive wasn't worth the money.

NICE determines what's valuable by assuming that anything that costs too much isn't worth the money, even if it helps people live longer or better for a year. That so-called 'quality-adjusted life year' is the upper limit NHS uses to determine what it will pay for. To NICE, breast enhancements and Viagra are a bargain, but new drugs for stomach cancer are a waste of money.

Many comparative effectiveness advocates claim that in America, which spends more per person on health than Britain, the appraisals would only eliminate "wasteful" care. Tell that to Barbara Wagner. She's enrolled in Oregon's Health Plan which used comparative effective analysis from Oregon's Drug Effectiveness Review Project to tell her it wouldn't pay for Tarceva, a drug proven to extend life in people with her particular type of lung cancer.

DERP receives funding from the federal government's Agency for Health Care Quality and Research, which already produces comparative effectiveness research. AHRQ also funds the comparative effectiveness institutes of HMOs who, along with DERP, crank out reports used by Medicaid and insurance plans to ration drugs for cancer, mental illness, arthritis and other serious disease in over 25 states.

AHRQ and these organizations would essentially run the new Institute with a budget of about $300 million a year. The legislation says they should do large studies that compare one drug or device to another. Such research take years to complete. All the better if you want to dodge paying for some new cancer drug or medical device. And such studies ignore racial, gender or genetic differences that allow doctors to match the right treatment to the right patient. That makes it easier to conclude that there is no difference between any treatments, and to recommend using the cheapest available.

Comparative effectiveness fans point to the ALLHAT trial (Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial) as another "gold standard" for what they want. That five-year, 42,000 patients trial compared older blood pressure drugs (diuretics) against newer medicines in reducing heart attacks.

The study concluded cheaper diuretics were just as effective at reducing death from all forms of heart failure. Michael Weber, professor of medicine at Downstate Medical Center and a study adviser, points out diuretics only seemed better overall because the study produced a 40 percent excess stroke rate in African American patients who were given a type of blood pressure drug called ACE inhibitors. It's known that blood pressure in African Americans responds poorly to ACE inhibitors. The one-size-fits-all approach to treating hypertension taken in ALLHAT exposed black patients to certain danger and even death.

Comparative effectiveness is marketed as a tool for promoting better health and universal coverage. In fact, it's used mainly to deny people care when they need it most by the folks holding the purse strings. Both NICE and the new Institute will ration care by deciding some lives are worth saving and others are not. The difference is, in America, the insurance companies have found a way to have us pay them to do it. - Bob Goldberg

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