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Tuesday, August 11, 2009

Health Care Rationing in UK: Rational, Humane, Better Than US

I just came upon an interesting Tech Nation podcast from July 21 about health care in Great Britain. Host Moira Gunn interviews Sir Michael Rawlins, chair of the UK's National Institute of Health and Clinical Excellence, the body charged with deciding what treatments the National Health Service can afford.

I know, your "Rationing!" alarms are going off already. It is true that in Great Britain, the government's single-payer system doesn't cover every drug and treatment. But the decision makers are not bureaucrats. They certainly aren't profiteers (as they are in the U.S., where an inusrance agent always stands between you and your doctor). As Rawlins explains it, the decision makers are health care professionals, folks who take a day off work once a month to come to London to serve on advisory committees. The government reimburses their train fare, but these decision makers get paid no salary for the hard decisions they must make.

And how do they make those decisions? Here's my rough translation of Rawlin's explanation (do listen to the whole interview, make sure I got it right):

Rawlins explains that each year, Parliament sets a budget for the National Health Service, and the NHS must then stay within those fiscal limits. NHS thus works to make that money work as hard as it can. Every possible treatment has an opportunity cost: spending a lot of money on one costly treatment deprives many others of cost-effective health care.

Thus, the advisory committees look at the improvement a new treatment provides compared to existing forms of treatment. They calculate an "incremental cost-effectiveness ratio." If that ratio is too high, NHS doesn't cover it.

Now that may sound cold and mathematical. But Rawlins emphasizes that there are no strict numerical limits. In each case, the advisory committees look at the particular circumstances. They give special weight to end-of-life treatments, as they recognize the special value of our final months as a time when we can make forgiveness and see births and birthdays. They pay attention to the impact of their decisions on disadvantaged populations, trying to help those who need help the most.

Rawlins cites recent examples of two drugs, one for Lou Gehrig's disease, one for flu. Both drugs had estimated cost-effectiveness ratios of £38K per year, above the general standard of £30K per year. If the process were purely mathematical, the advisroy committees would've denied coverage for both drugs. But the flu drug reduced symptoms from six days to five. The Lou Gehrig's disease drug allowed patients to avoid tracheostomies. The committees heard from patients that having a tracheostomy was simply awful, in a way that another day of the flu just isn't. The advisors thus recommended coverage for the expensive Lou Gehrig's disease drug but not the expensive flu drug.

This is rationing. But this is not fascism or the Anti-Christ at work. This is a sensible, compassionate use of limited resources. That beats America's rationing-by-wealth any day.

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