A thought-provoking article in last Sunday’s New York Times posed this health care scenario:
“You have advanced kidney cancer. It will kill you, probably in the next year or two. A drug called Sutent slows the spread of the cancer and may give you an extra six months, but at a cost of US$54,000. Is a few more months worth that much?
If you can afford it, you probably would pay that much, or more, to live longer, even if your quality of life wasn’t going to be good. But suppose it’s not you with the cancer but a stranger covered by your health-insurance fund. If the insurer provides this man — and everyone else like him — with Sutent, your premiums will increase. Do you still think the drug is a good value? Suppose the treatment cost a million dollars. Would it be worth it then? Ten million? Is there any limit to how much you would want your insurer to pay for a drug that adds six months to someone’s life?
If there is any point at which you say, ‘No, an extra six months isn’t worth that much,’ then you think that health care should be rationed.”
For anyone thinking seriously about how the New Zealand public health system will meet the expense of providing care for a rapidly aging population, this is a “must read” article. While written in the context of current policy debate in the US, key examples of the “workings” of health care rationing are drawn from British and Australian experience.
Indeed, the handling of the cancer drug Sutent, mentioned above, caused considerable controversy in Britain, when its use was first declined by that country’s National Institute for Health and Clinical Excellence (with the ironic acronym, NICE).
According to figures just released by Statistics New Zealand, the number of people aged 50 and over will grow 63% in the 25 years from 2006-2031, compared with only 5% for those under 50. Coincidentally, an update by health planners at the Hawke’s Bay DHB meeting last week emphasized the significance of our region’s aging population (along with our region’s disproportionate Maori population) as a “structural” cost driver — older folks present at the hospital with more complex medical needs and they stay longer. A “fact of life” one might say. And those over-65 are also more likely to be over-prescribed, driving up those costs as well.
The issue of rationing health care is immensely difficult, economically and ethically, forcing trade-offs that are only likely to become more excruciating. But rationing and the debate around it is unavoidable.
Of course New Zealand’s most recent example is Herceptin, the breast cancer drug. Here’s how a critic writing in a thoughtful American magazine, The Atlantic, described the pre-NZ election situation:
“You can err on the side of patient safety or on the side of cost. New Zealand chose the latter. It just didn’t want to admit its priorities, preferring to conflate economic and medical questions. No public figure wants to seem heartless, after all.
That surely accounts for the most damning inconsistency in New Zealand’s policy. When Pharmac was denying Herceptin to early-stage patients, it was fully funding the drug, without limitations, for women with advanced metastatic cancer, who are just buying time. A purely rational calculation would suggest the opposite course: letting patients with advanced cancer die while shifting the money to early-stage patients who, if treated, might survive for decades. But once a treatment has become standard practice, taking it away is hard.”
We all know how this one turned out.
As individuals, we need to give the rationing debate the most sober thought we can. Although the critical decisions will be made in Wellington, as “objectively” as we might wish them to be made, public decisions this fundamental will always be political … in the sense of demanding public acceptance. Consequently, we should still expect our locally-elected Health Boards to help inform and lead us through the tough choices ahead.
One can only hope our Hawke’s Bay DHB is up to this leadership task and engages the public appropriately.