We may see more consolidation, too. It’s possible that the big fish will swallow up some carriers that have a harder time competing. If we have a few mega carriers as market leaders, just imagine what might happen to prices. It’s going to be easy for them to set prices as high as the market will bear. You don’t have to deal with any of this in England, right?
CS: Right.
How decisions get made in Britain
CS: In the UK, people know they are getting healthcare, and they are paying for it through taxes. They know those things have to be weighed somehow. They want to know their taxes are well spent. The National Institute for Clinical Excellence, or NICE, which studies medical evidence and makes recommendations to doctors, is quite well accepted now as the best way to do this.
I find it interesting that there is nothing similar in the US. Not necessarily a statutory body like NICE but any kind of independent body that says, ‘This is best practice; this is cost-effective and this isn’t.’
TL: NICE is relatively new isn’t it?
CS: It’s been going since 2000. The essential point in our system is to balance the two sides of citizen engagement with the NHS—the patient side and the taxpayer side. That’s why NICE has been accepted. It’s sort of an equation: How much treatment are you going to give versus the interest of the taxpayer, and not paying through the nose for stuff that doesn’t work. NICE has gone though more or less every NHS treatment, usually two or three times, and is able to say, ‘This is the gold standard of care you should get.’
TL: Then they decide how much it costs to keep someone healthy?
CS: In the early days they sort of solved this. They had these concepts of “quality-adjusted life year.” In other words, What is your life worth per year if you’re healthy; how much less if you’re in a certain amount of pain; and even less if you’re in chronic pain all the time. The method for figuring that out is well established, and experts understand it and think it’s a robust model.
I don’t think the public has any idea how they calculate it. But they do understand the figure they’ve picked out—30,000 pounds [nearly $50,000 at current exchange rates] is what the government will pay for one year of good quality life. And I think people widely accept that. It’s an arbitrary number, but it’s a large number to an average person, and people don’t see it as stingy as far as I can tell. If a treatment comes in under that, then NICE will recommend it, and if it doesn’t, they won’t.
TL: I’ve heard that’s sometimes controversial.
CS: This obviously leads to intense discussions with drug manufacturers whenever there’s a new drug, and the drug companies desperately try to make sure it comes in under the threshold. If treatment is calculated to cost more, they claim ‘you haven’t you looked at this fact or that fact.’ That’s always a protracted process. But I think fundamentally people feel that it works, to determine the best and most cost-effective treatment.
TL: I remember some very negative and sensational press coverage when NICE began.
CS: When NICE was set up, there was a standard genre of story—you found a lovely family, made a nice picture; they want this life-saving drug and the bureaucrats have said, ‘No.’ You could always find tough margin calls, but those stories have dried up a bit now. Not many newspapers do them anymore because the public has accepted that sometimes there are hard cases, but that generally this process does work.
TL: You really can’t. There’s a willingness on the part of the press to accept what they’re told, without weighing claims and seeing if one claim is more meritorious than another. We have this cult of balance, and it’s a problem.
In the US, you need to remember one thing; what was passed was basically a Republican plan. The ideas had been in the academic literature for years, and they were ideas Republicans would be totally comfortable with. But instead, the Republicans have run against their own plan, so to speak. And when the press fell down on the job of bringing the people along, it made it easy for Republicans to move on this strategy.
Amen to that. The lack of real, probing reporting on the health care act is a serious failure in the MSM. The fact that the enabling legislation effectively prevents the IRS from collecting the tax imposed when someone refuses to buy health insurance is almost totally ignored. There is no attempt to either explain this or to assess the potential impact on the costs of the program. If I were still an editor, I'd be angry if a reporter submitted to me the sort of lazy, "balanced" junk I regularly read in the press about the act.
#1 Posted by Tom Barry, CJR on Wed 10 Oct 2012 at 10:29 AM
Hope to hear more about this surprising info about how NICE advocates for rather than denies good care:
CS: It’s important to note that what NICE has done is make it more likely someone will get treatment, because you will often find a treatment NICE has approved that is in fact not given locally because of these rationing decisions by local health boards. They might say it’s too expensive, we don’t have the money here. But the fact that NICE exists and has said this is a cost-effective treatment means that people can say well, no, hang on a second. I should be getting that because it’s NICE-approved and therefore you should be giving it to me. It has given people the power to demand treatment that NICE has approved.
But NICE is not the same as IPAB (right?). And IPAB is the current focus for "death panel" fear mongering? Does IPAB have potential to evolve like NICE?
It's possible that most Americans know the most about European health care through through British TV & film---we might know the British system better than the others. I have wondered if Doc Martin is good or bad advertising for universal care, particularly because it focuses on a surgeon reluctantly practicing primary care and the doctor's office looks old and run down. But just recently William & Mary and Call the Midwife portray very engaging struggles to deliver care by very passionate, caring, and competent health professionals---who are not MDs. So we get mixed glimpses of British care---but very little about other countries. We probably have no other view of the French system than the death of Diana and in Michael Moore's Sicko. MM covered Canada but elsewhere very little about it. International Mystery on MHZ shows a little bit about some others, mostly Sweden but occasionally Germany, some Italian. So other than TV & film, we have few opportunities to learn (accurately or inaccurately) about other health systems.
Good info presented here. Hope to see/hear more about it.
#2 Posted by MB, CJR on Thu 11 Oct 2012 at 01:09 PM