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.
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