TL: The American press hasn’t really covered NICE and it’s decisions much. A case in point: When cost-effectiveness and clinical effectiveness for new treatments was being discussed during the health reform debate, I did an interview with Andrew Dillon, who heads NICE, hoping to encourage reporters here to look at NICE. There was no interest. Yet at the time there was considerable talk in Congress about how we could not have any government body doing cost-benefit analysis on drugs and other therapies. Congress set up an apparatus to consider clinical effectiveness but not cost, under the Affordable Care Act, that’s just getting started. NICE is very different. The very thought of a government body questioning medical treatments sparked our “death panel” debate. People still believe they exist.
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.
Reorganizing how care is delivered
TL: We’ve had a lot of talk about how care is delivered, and the Affordable Care Act has made money available for organizations that improve the way care is delivered.
CS: The thing policy people in the NHS talk about the most is the need to reorganize the system. They want to reorganize the system away from the strict primary and secondary care division that was set up years ago in the old industrial-accident world, where people would get sick, come in and get better, and go away. They want a system and a way to manage people with longterm conditions. Those people account for two-thirds of the NHS spending. Their care is often done inefficiently, particularly for elderly people.
Theoretically it should be easy to improve healthcare at home in the community in a sort of top-down system. But in fact, it’s proven extremely difficult, because people are resistant to any sort of change in the way health systems are set up. The infrastructure for community care is not as good as it should be. Lots of efforts are being made to change that, so far, with limited success, really. Presumably those pressures exist in the US, and I’m wondering how dominant they are.
TL: In the US, if you ask people where they want to be cared for, it’s in the community. And yet our financial payment structure is not set up to support that. People go to nursing homes because federal and state dollars are directed toward nursing homes rather than toward home and community care.
This is going to be a big issue going forward—especially since states can now decide if they want to expand their Medicaid programs. States are really balking at spending much more on Medicaid.
CS: Who does pay for residential and nursing home care?
TL: Medicaid pays for about half of all nursing home stays. Private long-term care insurance pays for a small portion, and families pay the rest.
There hasn’t been much attention to long-term care in the press here. I tried to urge the press to cover it during the debate, but few reporters did. It’s like it’s not that interesting— and yet it’s going to be very interesting as time goes on, as America gets older and the costs of care outstrips what families can afford to pay.
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