Michael Moore likes nationalized health-care systems, especially
the one in Cuba. It’s too bad he can’t secretly move to Havana in
order to anonymously sample the wonders of Cuban health care.
He probably could move to Great Britain and enjoy the wonders of
the National Health System (NHS) like any other resident. One
aspect of that experience would be limited access to the newest
pharmaceuticals.
Health care is again emerging as an important political issue.
And the U.S. system is seriously flawed. A weird hybrid of private
and public, American medicine is dominated by third-party payment,
with about 80 percent of all health-care dollars paid directly by
someone other than the patient. Such a system is neither efficient
nor accountable.
However, nationalizing care typically saves money by denying
treatment. Political bodies or bureaucracies decide who is entitled
to what, and spend accordingly. The well-to-do flee to private
clinics or other nations, including America, for better treatment.
Everyone else suffers from inadequate or delayed care. The ill
consequences are highest for those suffering from diseases
requiring immediate, sophisticated, and expensive treatment.
For instance, one bad aspect of a longer life expectancy is a
higher incidence of cancer. Thankfully, advances in treatment —
from surgery to pharmaceuticals to radiotherapy — mean that many
more patients survive. In Europe, despite more diagnosed cases of
cancer “the mortality rate is stabilizing, however, and in some
countries is on the decline,” write Nils Wilking of the Karolinska
Institutet and Bengt Jonsson of the Stockholm School of
Economics.
But survival depends on receiving the best care. Inadequate
access to oncological drugs, in particular, means unnecessary
suffering and death. Speaking on behalf of the three million
Europeans diagnosed with cancer annually, John F. Smyth,
President-elect of the Federation of European Cancer Societies,
puts the issue squarely:
cancer is a significant cause of morbidity and
mortality in Europe, and scientific advances have given us the
potential for more treatment approaches than are currently
provided. New medicines have no benefits unless they are used by
the patients who need them, and the need to balance benefits, costs
and available resources should not prevent patients from gaining
access to novel drug therapies.
Obviously, cross-national comparisons are complicated.
Nevertheless, the differences in cancer treatment and survival
rates are significant. Wilking and Jonsson survey access to cancer
drugs in the U.S., a score of European nations, and several others.
Their conclusion: “Our report highlights that in many countries new
drugs are not reaching patients quickly enough and that this is
having an adverse impact on patient survival. Where you live can
determine whether you receive the best available treatment or
not.”
Why? In a globalized world there is no issue of information
access or product availability. Rather, the problem is regulatory
regime.
Observes Smyth: “There are considerable variations in the time
from a license being granted to the actual availability of new
medicines in different member states and the speed at which
patients are able to gain access to new cancer drugs. Although
there is little excuse for lack of knowledge of these new advances
amongst the medical profession, the health-economic issues that
influence whether or not new medical approaches can actually be
delivered to the individual patient are often poorly
appreciated.”
In fact, one of the most striking features of nationalized
systems is their inequality. Although supposedly dedicated to
ensuring access to all, that access rarely is equal, varying among
nations as well as regions and classes within nations. The
differences are most acute in self-proclaimed workers’ paradises,
like Cuba, where the well-connected — as well as visiting U.S.
journalists like Moore — receive world-class treatment.
America gets good ratings on drug availability, despite the
vagaries of its medical system. Wilking explains: “In the U.S. we
have found that the survival of cancer patients is significantly
related to the introduction of new oncology drugs.” Thus, the
researchers add, “it is clearly in the best interests of cancer
patients that innovative drug therapies are made available as soon
as possible after market authorization. Reduced or delayed access
to cancer drugs has a very real impact on patient survival.”
Europe is much more a mixed bag. Write Wilking and Jonsson, “Our
analysis indicates that there are imbalances and inequities in the
ability of cancer patients to access cancer drugs in Europe, with
access varying according to the country of residence. There are
large differences between countries with regard to the level of
uptake and the time period over which cancer drugs become available
to patients.”
Austria, Spain, and Switzerland were best in adopting new
medicines. Wilking and Jonsson also point to Italy in selected drug
therapies. At the other end of the spectrum were the Czech
Republic, Hungary, Norway, Poland, and United Kingdom, which, the
researchers report, “were consistently identified as below-average
adopters of new cancer drugs.” Indeed, Wilking and Jonsson add,
“Four years after the drugs’ introductions, several countries still
have a large patient population not being treated.” Ironically, the
UK is number one in cancer research funding yet “lags behind other
EU countries in terms of the ability of cancer patients to access
new drugs.”
Failing to provide the best oncological pharmaceuticals to
patients may save governments money — in the short-term, anyway —
but will cost patients dearly. As Wilking and Jonsson opine, with
extraordinary understatement, “This represents a substantial loss
to patients.”
The problem is simple: citizens of the UK and several other
European countries suffering from breast cancer, colorectal cancer,
lung cancer, and non-Hodgkin’s lymphoma are far less likely to
receive the latest, most effective medicines. Columbia University’s
Frank Lichtenberg figures that access to newer, better drugs has
increased both one-year and five-year survival rates. Indeed,
pharmaceuticals account for 50 to 60 percent of the recent increase
in survival rates. Too bad if you’re born in the wrong European
country.
Government domination of the health care systems creates the
biggest impediment to widespread access to new drugs. Politicians
simply decide that the best way to save money is not to pay for
expensive new pharmaceuticals. Explain Wilking and Jonsson:
While there are a number of procedural barriers,
perhaps no obstacle is more dominant on the uptake of new drugs
than the structural hurdle of budgetary limitations. The ability of
patients to access cancer drugs is highly dependent on the
allocation of appropriate and adequate funding or financial
resources within the healthcare systems to facilitate the
availability of these drugs and the speed at which they may be
accessed. This issue of funding for new cancer drugs has become
critical as a result of the introduction of new and innovative
cancer drugs such as targeted therapies.
Although cancer drugs account for less than 10% percent of the
total healthcare expenditures for cancer and represent 3.5-7% of
the total drug costs, they are an easily identified target. In
efforts to manage healthcare or budgetary costs, healthcare policy
and decision makers may therefore seek to delay or restrict access
to these new innovative drugs. Such actions have very real impact
on survival rates.
The delays vary by country but often are a year or more. Of the UK,
write Wilking and Jonsson, “there are significant delays in
reimbursement and availability of new drugs.” But Britain is not
the worst. The researchers write: “For Poland, the true delay could
not be calculated as no new innovative products have been
reimbursed for almost seven years.”
Of course, this thinking tends to be penny-wise and
pound-foolish. Wilking and Jonsson figure that the cost in
lost-work years alone from cancer is three times the cost of all
cancer drugs. Saving more lives and keeping more people healthy
would yield substantial economic benefits. Then there’s the little
matter of government living up to the responsibility that it
assumed when it took over health care, to promote the health of its
citizens.
The denial of cancer drugs by government-run systems is ironic,
but not unexpected. Market-oriented health care actually values
patients. Medical costs in America are high, but patients commonly
have access to the newest and best pharmaceuticals. In contrast,
nationalized systems dedicated to equality treat people as numbers,
sacrificing their lives to save a few pounds or euros.
Wilking and Jonsson advocate a series of reforms, including
expediting the review time for new drugs, speedily conducting any
economic reviews, and “ensuring that appropriate and adequate
funding for new innovative cancer drugs is available in the
healthcare system and hospital budgets preferably on a proactive
and not reactive basis.” Unfortunately, the researchers might as
well as call on the Easter Bunny to distribute pharmaceuticals
instead of eggs. Nationalized systems are inherently biased against
providing adequate care for their citizens.
In mid-May Britain’s National Institute for Health and Clinical
Excellence (NICE) announced that it was rejecting Erbitux for those
suffering from head and neck cancer (following a similar decision
regarding patients being treated for bowel cancer) because the
medicine allegedly did not offer a sufficient therapeutic advance.
Yet the Scottish Medicines Consortium already had approved Erbitux
for patients in the north of Britain. Oncologist Nick Slevin
complained: “The decision from NICE ignores the complexities and
pragmatism of clinical practice.”
In fact, the basic decision was money. Noted Institute CEO
Andrew Dillon: “The NHS has finite resources and it is our job to
ensure that these are spent on treatments that confer enough of a
benefit to patients in relation to the amount of money they cost.”
The fewer Pounds spent, the fewer treatments provided.
America’s medical system needs fixing, but the way to do so is
to expand choice, empower patients, and increase accountability. At
least a private, market-based approach is based on the assumption
that the first goal of a health care system is to provide health
care. In sharp contrast to the nationalized systems imposed by so
many other governments.
