What medical treatments aren't covered in nations with comparative effectiveness plans

Factual Questions
1

In areas like the UK they use the NICE program to determine which medical treatments are cost effective, I think the cutoff is about 45k a year for a quality-adjusted life year. I believe nations like France have a similar system, but I don’t know the name. I have no idea what other nations use.

But it seems the only interventions that would fall below that reading are medications for end of life terminal diseases (kidney disease, cancer, etc) where the drug may cost 50k but only extend life 6 months.

Are there surgical procedures that are not covered in nations which have QALY and comparative effectiveness litmus tests because they are too expensive? ie, would a joint (hip, knee, etc) replacement on someone only expected to live another year or two be denied?

A standard of 45k a year for quality adjusted life year seems like it would only exclude a handful of treatments in those with terminal illnesses or people in their 80s since the cost may come to more than 45k a year.

And aside from expensive new treatments for end stage diseases, and maybe joint replacements in those with life expectancies of less than 1-2 years, I don’t know what else would be above the cost.

2

In Canada, my wife’s grandfather fell and broke his hip at 85. They did a replacement that night (although my 55-yo boss had been waiting and gotten the run-araound for 16 months before he got his.) Sadly, the grandfather had serious infections from the operation, which took a few months to recover from. Then a year later he went downhill again and died after 6 months’ hospitalization.

So it depends. If it’s a pain issue - take meds instead for awhile - you go on the waiting list. If it’s urgent, can’t function without it, they bump you to the head of the line.

I have never heard of any mathematical formula, but I’m sure the doctors consider - “this elderly person has entered hospital for multiple conditions, likely never to leave. A major procedure is just a waste of time”. In fact, Robert Latimer was convicted for the mercy killing of his severly retarded daughter who had cerebral plasy and was severly retarded. To relieve the pain from stretched muscles, doctors were talking about removing her thigh bones, which would be a significantly expensive treatment; and this was only one of many she had undergone. No discrimination on basis of “good to society” there.

There was a big fuss in the media a few years ago about some provinces denying transplants to the retarded. The media made it sound like “we don’t want to do a transplant because this person is defective and might as well die”. In fact, the logic was more sensible - a major transplant of lung, heart, kidney, etc. would require someone to carefully take a serious regimen of drugs for the rest of their life, and there was a question whether some people could manage that simple task.

3

I can’t answer your question directly, but this PBS program recently compared health plans among major democracies.

The program is a real eye-opener and very well presented.

4

Yeah, I saw that one a while back. The Taiwan story was extremely interesting, and the way they basically constructed a UHC system from scratch was the best story IMO.

Vermont recently passed a universal health care plan designed by the same guy who designed the Taiwanese system, Harvard professor William Hsiao.

http://www.boston.com/bostonglobe/editorial_opinion/blogs/the_angle/2011/04/vermonts_single.html

It should be interesting to see how Vermont turns out.

5

Canada has health plans managed by each province; with standards set by the federal government, under threat of withholding much of the cash. So details vary from province to province, but essentially are pretty much the same. Unlike the USA, we only have 10 provinces and since the plans are pretty much the same, not a lot of cross-border comparisons. Considering how cnfusing the laws are in the USA from state to state, I shudder to think if each state sets its own standards on UHC what will happen.

I used to think the “death panel” thing was right-wing hysteria, but last year there was a case of an eldery jewish man in Winnipeg - his family wanted all measures used to keep him alive (for religious reasons) and the doctors basically said he was dying and they did not want to keep him alive. It took a court case to settle things. There was some dispute whether this was a financial issue, a quality-of-life/pain issue, or just the doctors being hostile at being questioned.

6

“Yes, death panels do exist. They exist inside the big health insurance corporations that every day make decisions on whether or not people enrolled in their health benefit plans will get the care their doctors believe might save their lives. I know this firsthand from nearly two decades inside the insurance industry.” …

“Last year, when Democrats were in charge of Congress, the House Energy and Commerce Committee conducted an investigation into denials of coverage in the private insurance market, although the investigation was limited to denials for pre-existing conditions. The committee found that over a three-year period, the four big insurance companies it investigated had denied coverage to more than 600,000 people who had been treated in the past for a broad range of medical conditions and that the number of coverage denials had increased significantly each year. The lawmakers found that one of the companies maintains a list of 425 medical diagnoses that it uses to refuse health insurance coverage permanently to many applicants.”

Source: http://www.prwatch.org/news/2011/03/10396/death-panels-fact-and-fiction:
The problem in my view is that insurance, with their profit motives, should not be the ones making life-and-death decisions. However, somebody has to make the tough call and prevent needless medical procedures which waste time, effort and money that can be spent on patients who have a reasonable chance of benefiting from treatment.

Suppose after an accident, somebody’s child is brain dead. The parents don’t want to “pull the plug” (for whatever reason, perhaps religious.) There is no hope of recovery–none–the question then becomes: “Is it justified for a hospital to keep the child alive at tax payer expense?”

The vast majority of super-expensive medical costs comes at the end of life. If a procedure will have little effect on the quality or longevity of life, where does a rational, sensitive person draw the line?

People will die while tests are being done, or while doctors consult, or maybe errors are made. This is regrettable but regardless of the system and safeguards in place, this will continue because human beings are…human.

Most people are so afraid of dying, and we’ll sue for any reason at all, but we need to deal with this issue on a macro level, away from the emotions.

Talking with medical personnel about the options available at the end of life seems only logical, at various stages of life. This seems fully justified and wise to me.
Related:
The Death Panels Sarah Palin Doesn’t Want You To Know About

7

I guess the OP question is - not so much, will they do endless procedures with no hope of success as the patient has entered the death spiral?

My interpretation of the OP is - will they do operations on, say, otherwise healthy old people who are simply well past their prime? Would the Queen Mother have gotten new hips (when she was what? 85?) if she’d been anyone lesser?

OTOH, my mother got 2 hip replacements at age 75 even though she had difficulty walking anyway due to serious Parkinsons Disease (and died of a heart attack 5 years later, barely able to stand or walk short distances, even with a walker). Again, I don’t see a lot of the “you’re not worth fixing” mentality in Canadian health care.

8

French here. Never heard of that. Let me know if you find the name.

9

Bolding mine.

There’s no such system in France as far as I know(In fact, generally speaking, the French healthcare system is very different from the British or Candian system and more similar to, for instance, the German system) .

I haven’t heard of someone being denied surgery or whatever else on the basis that it wasn’t cost effective. I suppose that on an individual basis, some doctors or hospitals might decide that it isn’t worth it to try some complicated intervention or another, but to my knowledge, there isn’t any general policy that would result on not covering a procedure because the patient is too old/too ill/whatever and the procedure too costly.
The situations that could be problematic are much more mundane than that. For instance, dental care and glasses are very poorly covered.

10

Locally, you get NHS funding for one cycle of IVF. Funding for iontophoresis and some cosmetic surgery has recently been withdrawn.

All still available if you can afford to pay out of pocket though- e.g. a lot of local couples go to Barcelona for private IVF.

Can’t think of anything else off the top of my head other than some of the very expensive chemo drugs which have already been mentioned.

Someone likely to die in 1-2 years probably won’t be fit enough for joint replacement surgery. Rather than any concerns about the operation being a waste of money, will be concerns that the patient will die on the table or immediately post-op.

11

I believe the French system is called the French national authority for health.

http://www.commonwealthfund.org/Content/Publications/Issue-Briefs/2009/Jul/National-Authority-for-Health-France.aspx

12

My question was more or less that since people do have to ration health care in some fashion, the best rationing mechanism seems to be evaluating how much quality of life you get per unit of money invested, and then treating based on that. If cheaper treatments are available, or if a treatment costs 6 figures but only extends life a few months it isn’t worth investing in.

So if that is the system, what treatments aren’t covered? Most medical treatments seem cost effective, the only ones I could think of that wouldn’t be cost effective are expensive surgeries and expensive medications for people at the end of life. That and maybe using an expensive brand drug when a generic will do the same thing.

13

But that’s not what the OP is asking. That a new treatment has to be at least as effective as existing ones to be covered makes perfect sense. Or else, to give an absurd example, some pharm company could produce a new drug exactly as effective as aspirin, but for 50 times the price and have it covered.

The OP is asking whether some people will be denied a treatment on the basis that it isn’t cost-effective in the case of this particular person (for instance, they won’t get a hip replacment because they’re old) while others would receive it. While what you’re quoting is that a new treatment won’t be covered for anybody if it isn’t in some way better than existing treatments. Not the same thing at all.
ETA : Just noticed you’re the OP. Still my point stand.

14

May be, this says France doesn’t use a QALY measurement, but nations like Canada & Australia do, and Germany has something similar.

http://csdd.tufts.edu/_documents/www/2915Cohen.pdf

However the NICE program in England uses about £45000 per year (and England has one of the lowest costing health care systems in the developed world). And aside from some end of life treatments I don’t really know what would be above that cutoff. If you are 25 and have a major illness that requires 300k in treatment over the next 3 years, then very little after that that is still far below 45k a year since you’ll live another 5+ decades.

15

I have the April 2011 edition of the Northern Ireland Medicines Management Newsletter.

It suggests changing everyone on Epaderm ointment to Hydromol ointment. Both have the same ingredients, but Epaderm costs £1.52 more per 500g tub. The Newsletter suggests that switching everyone in Northern Ireland currently on Epaderm to Hydromol would save £33,000 annually.

It isn’t a death panel, but that’s generally the type of money saving advice GPs get. It isn’t " don’t refer this patient for surgery" it is " change all 1000 people on your list who take expensive antihistamine A to cheaper antihistamine B".

16

This isn’t exactly the same as “deny treatment”. IIRC, Canada generally has a rule to susbtitute generic drugs unless the doctor specifically forbids it.

As an example of new and emerging treatments: the latest treatment for MS suggests it is caused by constrictions in the neck veins creating a back pressure of blood in the brain, and “angioplasty” of those vessels will alleviate the symptoms. Quite a few people in Canada have paid their own way out of country to have the treatment, and anecdotally it works, sometimes miraculously. There have not been sufficient real medical tests to prove anything yet.

Meanwhile the medical establishment came out strongly against it, especially the groups with a vested interest in (a) continuing the status quo on research and (b) not wanting to be shown up as stupid enough to have missed such an obvious cause. Listening to conservative medical opinions (and wary of the costs) governments are being dragged reluctantly into paid “studies” but the treatment is not approved and not part of the general health plan for anyone yet. Part of the problem will be that the moment it is approved, there will be a massive backlog of people demanding immediate treatment; and other anecdotal evidence is that the treatment may need to be repeated every few years if the veins close up again.

Time will tell./