Managing Healthcare Costs: South Africa

Today's Managing Health Care Costs Indicator is 3.2 million

Imagine that there is an infection which can be detected through screening. There is an effective but expensive treatment, and many of those who suffer from the disease will die prematurely without detection and treatment. Further, imagine that those who don’t know they have the disease will transmit the infection through sex or through shared needles – leading to preventable deaths and disabilities of hundreds of thousands more.

This sounds like South Africa under Thabo Mbeke in the late 1990s - where the government denied that HIV was the cause of AIDS, and refused to fund screening or treatment. Researchers believe that 365,000 died due to the inaction of the South African government.

An article in JAMA last month reminds me that we don’t have to look very far to see a similar avoidable tragedy unfolding.

In the United States, Hepatis C is a scourge. About three quarters of those infected get chronic hepatitis. Two thirds of these have active liver disease and a quarter of those get cirrhosis. The viral infection causes liver cancer, and is the largest cause of liver failure (and transplantation) in the US. There is no vaccine, but a handful of (expensive) antiviral medications have recently been shown to be effective in lowering viral count, reducing new infections. There are recent reports that antiviral therapy has led to actual cures – a result we still haven’t achieved with highly active antiretroviral therapy for HIV infection.

There are 3.2 million Americans with Hepatitis C – and most of them (66-75%) don’t know they have it. About a million of those with Hepatitis C pass through the US correctional system each year – so we could diagnose many of these cases through voluntary testing. We could also treat newly-found cases of Hepatitis C – which could prevent future liver failure and prevent infection of others. It wouldn’t be easy, of course. The current drugs cost $30-60,000 for a 12 week course of treatment – it’s hard to imagine coming up with that kind of money in the prison system. Just like high drug prices make it hard to imagine South Africa treating all of its HIV-infected individuals with expensive HIV drugs in the days before generics were available.

We should start diagnosing and treating prisoners who have Hepatitis C. We also need to negotiate aggressively with the pharmaceutical industry to lower the prices of these lifesaving medications when they are purchased in bulk. Hepatitis C killed more Americans than HIV last year! We should not stand by and watch a public health failure like that of South Africa in the late 1990s.

The World, a public radio show cohosted by the BBC and the Boston NPR station, had a four part series on rationing health care around the world last week. The radio shows as well as the web material help demonstrate how hard it is to distribute scarce health resources.

The series starts in South Africa, where committees in hospitals determine who gets dialysis and who doesn’t. These committees started by considering “social worth,” but have moved to prioritizing those who would be good candidates for kidney transplants, and who could therefore get off dialysis quickly. If you’re a drinker, or if you’re overweight – well, dialysis could save your life, but it won’t.

The series moves on to the UK, lauded by health policy experts around the world, where the National Institute for Clinical Excellence (NICE) assesses comparative effectiveness and determines how much the National Health Service (NHS) will spend to save a quality adjusted life year (QALY). Right now the number is south of $50,000. If a new drug might help you but would cost more, it isn’t covered. NICE has been successful at pressuring drug companies to lower prices in exchange for access to the NHS market – but its authority to do so expires in 2012. It’s hard to feel good about denying a drug that could save someone’s life.

Next stop is Zambia, which can’t afford HIV drugs for all the HIV patients. The country has long had poor governance, and has a shortage of health personnel and medicines. The main method of rationing in Zambia is the queue. People have to wait a half day for a brief clinician appointment, and another half day for the pharmacist to fill a prescription. Those who cannot wait – perhaps because they are employed or have young children – go without life saving medications.

The final installment is a visit to

India

, where a resourceful pediatrician faced a shortage of ventilators during an influenza epidemic. She fashioned homemade continuous positive airway pressure machines from a few dollars of readily available supplies, and saved many dozens of lives. This is an example where disruptive innovation made an enormous difference. The homemade machines weren’t nearly as good as ventilators for these critically ill children. But the makeshift machines were better than nothing, and the physician improved them “on the fly” during the epidemic.

These stories point out that rationing is painful – and it’s not restricted to poor countries. We already ration care in the US by rationing access. It’s not easy for a Medicaid patient to find a dentist or a specialist in many states, as Medicaid pays very low rates. We might give FDA approval to a $90 a month medicine for cancer, but few eligible patients who don’t have generous insurance coverage will benefit from these medicines. In Arizona, Medicaid beneficiaries are dying because the state will not fund evidence-based transplantations.

We’ll be having more distributive justice conversations in the US, because we won’t be able to afford uniform access to all health care innovations as they are currently priced. The best way to minimize the number of times we refuse to offer useful therapy to patients is to lower the cost of interventions, but we’ll still face a demand for more health care than we can afford.