. "Appendix F Dissenting Opinions on Recommendation 3a." HHS in the 21st Century: Charting a New Course for a Healthier America. Washington, DC: The National Academies Press, 2009.
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HHS in the 21st Century: Charting a New Course for a Healthier America
Foreign models of centralized government decision makingshould not be applied to the U.S. health care system without fullconsideration of the implications and associated risks.
Much of the policy debate in Washington has focused on the adoption of some of the most controversial aspects of foreign models for HTA.2 Foreign models for HTA are generally premised on a basic fact that the government must ration care to a budgetary level rather than to the level determined by a physician to be appropriate for an individual patient. In these systems, lower-cost treatment options are promoted, even though they may be less effective than other available, more advanced therapies. In doing so, severe restrictions on access to the fruits of innovative medicine and medical technology are the natural result. It is inappropriate to endorse the broad application of budget-guided rationing in the U.S. health care system without a thoughtful analysis and evaluation of the implications for those Americans who would be subject to the government decision-making authority’s actions.3 I note that, although the report does not recommend rationing based on cost-effectiveness explicitly, no recommendations against such an approach are included.
In its discussion of these issues, the report also fails to recognize that there are potentially serious consequences to patients and Amer-
2
A frequently noted example of a foreign government’s model for HTA is the United Kingdom and NICE. If the NICE system were applied in the United States, American cancer patients could be required to experience one of the worst levels of cancer care in the developed world. For example, in 2006, the United Kingdom ranked ninth out of 28 European countries for male cancer mortality (where the first has the lowest mortality) and twenty-second out of 28 for female mortality. The mortality figures could be attributable to the slow uptake of new cancer drugs. See U.K. Department of Health. 2007. U.K.cancer reform strategy; Karolinska Institute. 2007. A pan-European comparison regarding patient access to cancer drug; Reuters. 2008. U.K.’s NICE says “no” to four kidney cancer drugs.
3
The connection to health budgets is prominent in the report. Specifically, in the discussion of practice patterns, the report relies on an assumption that up to 30 percent of health care spending in the United States could be eliminated if geographic variations in the care intensity were changed to the least intensive levels. This approach, as outlined in a preliminary analysis by the Congressional Budget Office (CBO), assumes that the increased costs in more intensive geographic locations are attributable to the use of more costly technology. However, this point has not been proven since important factors were not accounted for by the CBO. Importantly, the issue of regional variation needs to be addressed by assessing population and sociodemographic issues, facility and specialist access differences (e.g., access to specialized providers), and differences in payment systems employed by health care payers. It is an illusory perspective to assume that comparative effectiveness and cost-effectiveness research will address these issues.
