Subscribe to one of our feeds
Print
So what lessons can be drawn from the NICE experience?
First, whatever the carping, healthcare is, always and everywhere, a money pit, and in a state-funded system with limited resources, it is useful to make decisions about coverage on a rational, data-driven basis. The technical quality of NICE’s assessments, say doctors, is world-class. Even if they don’t appreciate its role in rationing medicines and healthcare technologies, they do appreciate having an independent, even-handed, and trustworthy body to turn to when they are weighing different courses of treatment. Second, those carrying out health technology assessments should be allowed to evaluate pharmaceuticals for off-label uses. Third, they should have a role in commissioning their own trials when drug companies, for commercial reasons, are not willing to do so, as with Avastin for wet AMD. Fourth, they should have some freedom to choose their brief, independent of political pressure, and a budget to carry out the necessary investigations. Fifth, they should be fast: Drugs that are likely to be major developments should be assessed for cost-effectiveness in parallel with licensing.
And a final lesson: the money should follow the health assessor’s decisions. In the U.K., with its taxpayer-funded system, there is no mechanism for bumping up the budget in response to costly central decisions; politicians, in sidestepping the hard decisions about which treatments to grant and which to deny, have also avoided the budgetary consequences of making those decisions. When NICE eventually ruled in favor of Herceptin, for breast cancer, some primary care trusts called for it also to rule on what other treatments should be dropped to balance the books. “Nobody has suggested what treatments we cut in favor of Herceptin—not the media, medical advocates of the drug, the courts who upheld patient appeals, or NICE. It would be especially interesting to know what the secretary of state for health would like us to cut,” wrote one group of doctors and health economists in the British Medical Journal at the time.
But a country where healthcare is funded at least in part by insurance premiums—whether state-run and subsidized, or not—could avoid this pitfall: a costly ruling from the health technology assessor could also trigger a proportional increase in premiums. Then everyone involved could have a NICE, grown-up conversation about costs and benefits—and the inexorable link between the two.
Helen Joyce is a Britain correspondent for The Economist, writing mostly on education, health, and science policy. Before joining The Economist in 2005 she edited Plus, a magazine about math and its applications published by the University of Cambridge, and Significance, the quarterly magazine of the Royal Statistical Society. She has a Ph.D. in mathematics from University College London.
