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Expensive new medications

  • 12-06-2016 7:28pm
    #1
    Registered Users, Registered Users 2 Posts: 2,881 ✭✭✭


    There's been a lot of news coverage over the last few weeks regarding new drug therapies for treating cancer (pembrolizumab and nivolumab) and cystic fibrosis (Orkambi) and the delay in deciding whether they will be funded by the HSE.

    While I completely understand how concerned patients and clinicians waiting on approval of these must be, I cannot help feel some of the attention given to these issues in the media has been an attempt to circumvent the usual economic evaluation and approval procedures. While the current process is not ideal, it is at least a fair and objective way of determining what new interventions should be paid for by the state to maximise the health benefit for everyone. A separate fund for cancer treatment has been suggested but to my mind, this would just be diverting funding away from some interventions to pay for others which are worse value.

    Does anyone have any thoughts on the current issues or any suggestions of a better way of doing things?


Comments

  • Registered Users, Registered Users 2 Posts: 7,401 ✭✭✭Nonoperational


    You are absolutely correct. It is very difficult to quantify extending life by a few months versus a cost of a few million. The analogy is that it's impossible to quantify for example a mother spending an extra 3 months with her children, however are we missing a cancer in another mother who has to wait for months for an outpatient appointment due to understaffing.

    It's a difficult area, but we don't have an infinite supply of funds. The other issue is that the drug companies should be forced to sell these therapies at a lower cost. They should, but they need to fund r&d etc, and for every hit they have a lot of misses.


  • Registered Users, Registered Users 2 Posts: 1,252 ✭✭✭echo beach


    penguin88 wrote: »
    While the current process is not ideal, it is at least a fair and objective way of determining what new interventions should be paid for by the state to maximise the health benefit for everyone
    I'm not sure that is strictly true or at least I don't know how we can know that the process is fair and objective. Unlike NICE in the UK which holds public hearings and has a great deal of 'stakeholder' involvement, it isn't transparent what criteria are used here or who does the actual decision making. What qualifications do they have to make them 'experts'? The fact that those decisions can then be overridden by politicians, often under pressure from the media and in particular one radio show, makes a mockery of the whole process. Whoever shouts loudest (possibly using a megaphone supplied by the drug companies) gets heard while 'Cinderella' areas like mental health continue to be underfunded.

    A separate fund for cancer treatment has been suggested but to my mind, this would just be diverting funding away from some interventions to pay for others which are worse value.
    A separate fund might have some merit if it contained 'new' money, possibly derived from a specific tax like a sugar tax or better still a financial transactions tax. The money would still have to be spent on treatments that give real benefits, not a few extra weeks of suffering serious side-effects.

    We need a real debate about how we want to spend the healthcare budget and it has to start with the unfortunate fact that resources are limited and every euro spent on one treatment is a euro less to spend somewhere else. Emotion has to have a place in the debate, as if we don't respond on a emotional level to the suffering of others we can't be caring health professionals, but emotion cannot be the sole determinant. We also have to look at the facts. The case for expensive treatments is always made using children and people raising families. Most of those getting treatment for cancer are elderly, who are no less deserving but never seem to feature in the campaigns for additional funding.


  • Moderators, Science, Health & Environment Moderators Posts: 4,754 Mod ✭✭✭✭Tree


    I'm always annoyed that the media and advocacy groups almost exclusively frame it as "the government won't buy these expensive drugs" and never "companies need to charge a lower price for the drugs". The efficacy stats are basically never trotted out either, just patient numbers. It seems to work as a campaign strategy for advocacy groups.

    Transparency in drugs pricing and national purchasing policy would be great, but will the media take any notice?


  • Registered Users, Registered Users 2 Posts: 2,881 ✭✭✭Kurtosis


    You are absolutely correct. It is very difficult to quantify extending life by a few months versus a cost of a few million. The analogy is that it's impossible to quantify for example a mother spending an extra 3 months with her children, however are we missing a cancer in another mother who has to wait for months for an outpatient appointment due to understaffing.

    It's a difficult area, but we don't have an infinite supply of funds. The other issue is that the drug companies should be forced to sell these therapies at a lower cost. They should, but they need to fund r&d etc, and for every hit they have a lot of misses.

    Very true. Quality-adjusted life years as used at the moment are definitely an imperfect measure of benefit. Disability-adjusted life years, which is the years of life lost from life expectancy due to disability/disease, has been used in economic evaluations in developing countries, but hard to know would it just introduce different problems compared to QALYs. You also touch on an interesting point RE understaffing. We know a lot about the value of new high-tech drugs but actually very little about the value provided by pretty much everything else that's done in the health service. I'd wager the majority of services provided are better value than these expensive drugs and that the €45,000/QALY threshold is too high as it is.

    To be honest, I don't buy the pharmaceutical companies' "high prices are needed to fund R&D" justification. Regardless though of whether the money goes on R&D or mainly marketing, it's a matter of economics, they'll charge a price that the market will bear. I'd be interested to see how a more widespread system of value-based pricing would work i.e. the more effective a treatment, the more governments pay. As well as getting better value out of our healthcare budget, it might also incentivise more innovation if drug companies that develop a new treatment are rewarded not based on their drug being superior to the alternative but rather on how much more effective it is.


  • Registered Users, Registered Users 2 Posts: 7,401 ✭✭✭Nonoperational


    Re the prices vs r&d, you are of course correct. It is the price we pay for a free market I suppose.


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  • Registered Users, Registered Users 2 Posts: 12,127 ✭✭✭✭Gael23


    The benefits of these drugs cannot be disputed. However the cost is phenomenal and would likely come at the expense of other things provided by the HSE. I'm not sure that a justification can be made fur that


  • Registered Users, Registered Users 2 Posts: 2,881 ✭✭✭Kurtosis


    There was an interesting article on this topic in the Irish Times today, Stroke patients are no less deserving than cancer patients.


  • Registered Users, Registered Users 2 Posts: 1,252 ✭✭✭echo beach


    penguin88 wrote: »
    There was an interesting article on this topic in the Irish Times today, Stroke patients are no less deserving than cancer patients.

    Thanks for that. Have to agree completely with him that there is a real danger that
    Those with the least resources for advocacy and those least able to articulate their case will end up with the worst care.
    Just remember it could be you.


  • Registered Users, Registered Users 2 Posts: 1,252 ✭✭✭echo beach


    Gael23 wrote: »
    The benefits of these drugs cannot be disputed.
    The benefits of many of them are hotly disputed. While some patients do enjoy huge, even life-saving, benefits not all do. The beneficiaries are naturally happy to be around to tell their story to the media but we can't hear from those who don't make it.


  • Users Awaiting Email Confirmation Posts: 5,620 ✭✭✭El_Dangeroso


    Tree wrote: »
    I'm always annoyed that the media and advocacy groups almost exclusively frame it as "the government won't buy these expensive drugs" and never "companies need to charge a lower price for the drugs". The efficacy stats are basically never trotted out either, just patient numbers. It seems to work as a campaign strategy for advocacy groups.

    Oh you betcha, this is totally a tack taken by marketing teams. Alexion got caught red handed media coaching patients and helping them with access to media outlets in Canada:

    http://www.cbc.ca/news/thenational/the-real-cost-of-the-world-s-most-expensive-drug-1.3126338

    Governments are pressured with these media articles featuring sick children.

    The only way to prevent this type of price gouging is to stick with rigourous metrics like QOLY's which though not perfect, are the fairest way to distribute the limited resources available that we have today.


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  • Registered Users, Registered Users 2 Posts: 2,816 ✭✭✭Vorsprung


    Am I right in thinking that the final decision goes to Cabinet for approval?


  • Registered Users, Registered Users 2 Posts: 1,252 ✭✭✭echo beach


    Vorsprung wrote: »
    Am I right in thinking that the final decision goes to Cabinet for approval?

    I don't think anybody actually knows.
    Our system of administration is that the Minister in a particular department has full responsibility for everything under the control of the department so that would mean the Minister for Health should have the final say. In practice he can't do anything without the say-so of the Minister for Finance who then makes it a cabinet decision so that there is 'collective responsibility.' It is an inefficient way to make any decision.


  • Banned (with Prison Access) Posts: 702 ✭✭✭Simon2015


    The Irish government should just produce generic versions of the drugs like they do in South Africa for aids drugs. Problem solved.



  • Registered Users, Registered Users 2 Posts: 1,252 ✭✭✭echo beach


    Simon2015 wrote: »
    The Irish government should just produce generic versions of the drugs like they do in South Africa for aids drugs. Problem solved.


    The difference is that Ireland is a much, much smaller country than South Africa and the drugs we are talking about are for conditions much rarer than HIV/AIDS is in Africa. The upfront cost of setting up production facilities would be far greater than the current cost of the drugs.


  • Registered Users, Registered Users 2 Posts: 2,881 ✭✭✭Kurtosis


    A similar idea which I have heard proposed is that governments should start commissioning drug research directly rather than paying through the patent system. There would obviously be a time lag for any benefit to accrue (i.e. to get any agents from pipeline onto the market) but it has the potential to provide more affordable drug treatment.


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