Wednesday, January 30, 2013

Can Our Politicians (or the Market) Improve on NICE?

The Disease Management Care Blog continues to welcome blog posts from outside authors.  This one is courtesy of Erik Tollefson, who works in the health policy field.  He can be reached at erikDOTmDOTtollefsonATgmailDOTcom.

In the halcyon dog days of summer 2009, U.S. politicians aimed their rhetorical fire on a rather odd target: the UK’s National Health Service (NHS).  With a vote on President Obama’s proposed health reform on the horizon, politicians hoped to tar the reform effort by association: The NHS was painted as inefficient; a decried relic of “socialized medicine” and state planning; some damning charges were levied against NICE (The National Institute for Clinical Excellence) as the putative “death panel” rationing potential life-saving treatments to patients.

In a strange turn of events, recent developments in implementing the ACA, particularly the legislative appropriation of basic benefits, may show the limits of the US political system in making important decisions for patients in an economically efficient matter.
Two recent examples may raise red flags.  ACA’s “Basic Benefit” program, originally conceptualized as a way for the federal government to standardize benefit programs offered on health care exchanges, was devolved to the states in order to dispel concerns over excessive bureaucratic intervention in the process. 

The result: massive lobbying by medical interest groups, including chiropractors and acupuncturists, to include their services in the benefit package without examination of medical evidence or economic value of their use. While these rent-seeking activities were seen as part and parcel of the political process, the Nebraska basic benefits proposal to offer a high-deductible plan did not pass muster. 

One economic case for the ACA (albeit a limited one) was predicated on leveraging efficiencies in drug prescriptions for generic drugs, particularly biosimilars.  Recent reports indicate, however, that biotechnology companies are trying to put additional roadblocks in the process to prescribe biosimilars, perhaps preventing the anticipated competition and forecast savings.
Although these are only a few examples, they have rapidly emerged as both the federal and (some) state governments have started to implement ACA provisions. 

Regardless of the political histrionics surrounding “socialized medicine”, the ACA is now (for better or worse) the law of the land. The issue of whether “rationing” exists in any health care system is a red herring; in a world of scarce resources, rationing is performed regardless of political ideology.

The real question is: how will rationing ultimately be conducted- out in the open as part of a rigorous deliberative process, or behind closed doors by legislative fiat?  In this sense, the US politicians’ attack on NICE was both prescient and half-correct:   the ACA would indeed give new power to legislators and bureaucrats to make decisions on the clinical and economic efficiency of medical treatments for patients, and NICE is the (sometimes unpopular) face of those rationing decisions.
At the end of the day, however, the implementation of the ACA raises seminal new questions about whether the business of politics can be separated from the dispassionate analysis needed to evaluate clinical treatments.  NICE is far from perfect: the institution has received withering criticism for tough decisions and a less than perfect methodology (e.g., the QALY).  One of the main challenges for US politicians, or the healthcare market, is whether they can come up with a better system. 

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