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National Review Online


Not so NICE

October 27, 2008

By David Gratzer

Does Jack Tagg represent the future of American health care? Tagg, a World War II hero, is losing the sight in his right eye from macular degeneration, a progressive disease that ends in blindness. His left eye is okay, though. While a drug is available on the market that would save his remaining eyesight, his health insurance refused to pay for it, since he's only half-blind. You might guess that Tagg is the victim of a heartless HMO, but actually, he's covered by Britain's National Health Service. The NHS relies for its funding decisions on the opinion of the quasi-governmental National Institute for Clinical Evaluation and Excellence (NICE), which ruled that Tagg's medication was too expensive.

An Englishman with an eye problem may seem unrelated to the U.S. election. But consider: many Democrats hail NICE as a model for America. With the Democratic party threatening to establish a filibuster-proof majority in Congress, a British-style health super-board could well be coming to our shores. In fact, some Democrats see this as just a first step, with Washington eventually reshaping clinical medicine. But NICE is nasty, and John McCain should warn Americans about the perils of unchecked Democratic ambition.

We can all agree on one thing: U.S. health care is getting more and more expensive. Health insurance premiums have roughly doubled since 2000. While no one doubts the excellence of American health care, costs are all over the map, literally. A Medicare recipient in Minneapolis, for example, uses half the health dollars that his Miami cousin does—without any difference in health outcomes. That's why Democrats talk about attaining better value for our health-care dollars. But how? Some Democrats suggest that NICE is the answer.

In the late 1990s, Tony Blair's Labour Government created the Orwellian-named NICE hoping to de-politicize decisions about the funding of new drugs and medical devices. New isn't necessarily better, the government argued, and such treatments could be extraordinarily expensive. But NICE has been controversial from day one, and its decisions have met with vigorous criticism from patients and physicians. Jack Tagg's case is just one among many. NICE also ruled that drugs called cognitive enhancers—the first-line agents used in North America to slow the progress of Alzheimer's Disease—weren't worth the money. Cancer drugs like Avastin, used to fight advanced colon cancer, didn't make the NICE cut, either; nor did Temodal, which is used in the treatment of certain brain cancers, such as Senator Edward Kennedy's.

Such rulings have sparked carnival-like press conferences led by angry patients, inspired blaring newspaper headlines, and prompted lawsuits. Not shy for a fight himself, Tagg showed up at 10 Downing Street with his family doctor—and the national media in tow. Taking a critical beating, NICE is undertaking a full review of its procedures and has quietly overturned many of its restrictions. Tagg now gets his medicine and the head of NICE publicly apologized for the sluggish approval of the drug.

Yet as controversial as NICE is in Britain, the concept is gaining popularity on this side of the Atlantic. Count former South Dakota senator Tom Daschle as a proponent. He speaks fondly of the idea in his book, Critical: What To Do About the Health-Care Crisis. "In other countries," he writes, "national health boards have helped ensure quality and reign in costs in the face of those challenges." Doesn't that sound NICE?

Daschle's view may carry real weight in 2009, as he is rumored to be under consideration for a serious role in a possible Obama administration (perhaps as chief of staff). And there is support for NICE-like solutions on Capitol Hill, too. In July, Senator Max Baucus, Chairman of the Senate Finance Committee, sponsored legislation to establish a British-style super-board. On the House side, at hearings of the Committee on the Budget, several committee members spoke favorably about the concept. (Disclosure: I was a witness.)

While the British version of NICE focuses on determining approvals for novel treatments, Daschle and others have pushed further, suggesting a super-board that would rule on all clinically effective treatments. With Medicare and Medicaid spending accounting for one-third of our health dollars, Daschle envisions an American NICE with a much broader scope: using public money, the federal government would demand that doctors, clinics, and hospitals comply with the best practices set out by the all-powerful super-board. Proponents of such solutions also speculate that private insurers would eventually follow the super-board's dictates, as well. In essence, the pro-NICE advocates envision a government takeover of all American health-care decisions in the name of efficiency.

And that would be disastrous. For one thing, the basic model of NICE is poorly conceived. While it's easy to target high-cost pharmaceuticals for oversight—doesn't everyone wonder about $50,000-a-year drugs?—the reality is that drug spending accounts for only about 10 percent of total health spending on this side of the Atlantic. High-end drugs account for a small fraction of that percentage. Besides, Britain hardly seems like a good place to look for health-reform ideas.

Cancer outcomes in Britain badly trail American results, in part because NICE stands in the way of patients getting their needed medicines. According to a recent Lancet Oncology study, English men have a five-year survival rate of 45 percent; for American men, it's 66 percent. The NICE concept is heavy on central planning and light on practicality. Can America's Medicare mandarins, who pay $600 for a toilet seat (due to non-competitive bidding), be trusted to tell doctors how to treat depression or heart failure?

Congress can lead on health care, not by weighing in on the treatment decisions, but by making it easier for people to make these decisions for themselves. For example, even the most basic pricing information in health care is not available to consumers. To get better value in health care, consumers need more data, which will allow them to compare services from different providers. But we need to have better information not just on prices, but on quality.

Obtaining a basic review of medical outcomes from providers is nearly impossible, because electronic medical records are scarcely available—and American health care has six incompatible information-technology systems. Of course, progress has been made recently. Patients are getting more information today than in years past—both from public sources (like the New York State report cards on cardiac mortality), and from non-government organizations (such as the Leapfrog Group, which rates hospital performance).

Congress can accelerate this trend. Washington should release more Medicare and Medicaid data, compel providers that serve recipients of these programs to release pricing information, and promote a standardization of medical records. Together, these ideas would lay the groundwork for a more competitive health-care system and dispense with the need for a big-government intrusion, which would leave us only with a NICE-sized problem of our own.

The McCain campaign should take note, and take action.

Original Source:



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