Comparative Effectiveness -- Maybe Not a Panacea?

A few weeks ago, the New England Journal of Medicine had an insightful article about the National Institute of Clinical Effectiveness, an independent government funded agency which determines which medications and procedures should be covered by the UK's National Health Service.  (Harvard full text URL)   The agency develops economic models and approves drugs or procedures when they cost less than $34,000 per Quality Adjusted Life Years (QALYs), and has discretion to approve values of up to about $50,000 per QALYs.   The title of the NEJM article was "Saying No Isn't NICE — The Travails of Britain's National Institute for Health and Clinical Excellence."  It turns out that British industry has been lobbying NICE and suing it when that fails.  It's not easy to say no!

This is especially important, because the Obama health care plan, the Daschle health care plan, and many others include an institute of comparative effectiveness to be sure we spend our health care resources wisely.   NICE is usually the model for this.

The New York Times followed up yesterday.  The article is introduced and concluded by a powerful anecdote about a patient sufferering from metastatic renal cell cancer who was hoping that NICE would approve an expensive Pfizer medication, Sutent, which delays progression of this cancer by 6 months for a cost of $54,000.  That's far outside of the allowable amount for  approval. 

Britain has a budget for overall health care, so it's clear that approving a very expensive medicine means that the NHS must make other tradeoffs.  It'seven  tougher in the US, where there is not a unified budget. 

The NYT article notes that the patient with metastatic cancer was losing his voice and having progressive trouble breathing.    It ends with a quote from his wife:

"It’s hard to know that there is something out there that could help but they’re saying you can’t have it because of cost,” said Ms. Hardy... “What price is life?”

In a theoretical world, we can all agree that above some cost threshold certain treatments just aren't valuable enough to be covered.  We feel differently, though, if we're talking about potentially extending the life of our own loved one.