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Selected news articles which highlight important policy issues.

News: Weekly Archives

News for the week of 11-22-2005

Valued Lives: Britain Stirs Outcry by Weighing Benefits of Drugs Versus Price: Government Arm Finds Pills for Alzheimer’s Too Costly, Angering Patients, Pfizer
Wall Street Journal, 11-22-05

Editor’s Notes:

“Free” health care in Canada or Great Britain comes with one very big catch: the government gets to decide what services and treatments are free and how they are provided. Take last week’s article from the Wall Street Journal on the use of one controversial Alzheimer’s drug in Great Britain. While the drug appears to help at least some patients with this devastating ailment, a national-health advisory committee for the government has issued a preliminary ruling that the drug shouldn’t be offered to patients because it isn’t “cost effective.”

Millions of patients around the world have taken drugs introduced over the past decade to delay the worsening of Alzheimer's disease. While the drugs offer no cure, studies suggest they work in some patients at least for a while.

But this year, an arm of Britain's government health-care system, relying on some economists' number-crunching, said the benefit isn't worth the cost. It issued a preliminary ruling calling on doctors to stop prescribing the drugs.

The ruling highlighted one of the most disputed issues in medicine today. If a treatment helps people, should governments and private insurers pay for it without question? Or should they first measure the benefit against the cost, and only pay if the cost-benefit ratio exceeds some preset standard? The U.S. generally follows the first course. Even the most cost-conscious insurers say they'll pay the price if a drug works and there aren't other options. Britain openly and unapologetically adopts the second course. If a drug or type of surgery costs a lot and helps only a little, it says no.
"There is not a bottomless pit of resources," says Phil Wadeson, finance director for the National Health Service unit that oversees hospitals and doctors' offices in Liverpool. "We reached the point a while ago where there is far more medical intervention available than any health-care system can afford."
The decision on the Alzheimer's drugs has sparked protests from pharmaceutical companies including Pfizer Inc. and Eisai Co., which co-market the leading Alzheimer's drug, Aricept. They say Britain is using a flawed economic model and will end up spending more on nursing-home care. More than 8,000 patients and caregivers sent angry letters to the National Institute for Health and Clinical Excellence, or NICE, which made the cost-benefit analysis.
NICE "has this strange mathematical formula they put heaven knows how many numbers into and out comes: `Yes, it's affordable,' or `No, it isn't,' " says Antony Dennis, a Web-site designer in the village of Ramsbury whose mother takes Aricept. "Things like the relationship my mum has with her grandson are probably not easy to put into that formula."

It is generally agreed that governments that offer socialized medicine over-provide many basic services and ration the rest. The logic behind this approach is that treating basically healthy people, or people with minor ailments (most people, most of the time) is relatively cheap. Treating truly sick people—with cancer or Alzheimer’s—is very expensive, and those treatments have to be rationed as a result.

European governments, then, ration care by saving money on the most ill patients. A fair trade-off? If you’re healthy, perhaps. But this approach also discourages innovation into diseases like Alzheimer’s, which are incredibly complex.

Governments, of course, must balance their budgets. But it’s a bit of a Catch-22 to demand more cost effective drugs tomorrow by not paying for some of them today. By restricting spending on admittedly effective medicines like Aricept, governments provide less of an incentive to research better Alzheimer’s treatments down the line. Which isn’t necessarily a problem, if your goal is to balance the budget.

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Medicaid Cutbacks Divide Democrats
Washington Post, 11-28-05

Editor’s Notes:

Just in case anyone was under the impression that only “heartless Republicans” favored “slashing” the growth of Medicaid (by 1.7% over ten years), the Washington Post notes that this cut in Medicaid growth was recommended by a bipartisan panel of governors who were actually trying to save Medicaid by making it even the tiniest bit more fiscally sane.

The changes would trim just 1.7 percent from a program expected to spend nearly $2.8 trillion though 2015, but the proposals have prompted bitter condemnation from congressional Democrats. …
"As the number of people without health insurance has increased for four years in a row, Republicans are charging ahead with $45 billion in cuts to Medicaid -- the health insurance program that provides medical care to America's poorest children and many of the survivors of Hurricane Katrina," House Minority Leader Nancy Pelosi (D-Calif.) thundered Nov. 18, just before the pre-dawn passage of the bill. "Republicans give new meaning to the words 'suffer little children.' "
What she did not say is that those changes were proposed over the summer by a bipartisan task force of governors, led by Virginia's Mark R. Warner, whose popularity in a Republican state has made him a rising star in the Democratic Party.
In fact, the most controversial provisions in the House bill were adapted almost word for word from a document drafted by Govs. Warner, Tom Vilsack (D-Iowa), Haley Barbour (R-Miss.), Janet Napolitano (D-Ariz.), Mike Huckabee (R-Ark.), Jennifer M. Granholm (D-Mich.), Dirk Kempthorne (R-Idaho), Jim Doyle (D-Wis.), Mike Rounds (R-S.D.), and Edward G. Rendell (D-Pa.), said Ray Scheppach, executive director of the National Governors Association.

To be fair, there is really a difference in perspective at work here. State governors actually have to make sure that their budgets are sustainable, while our Congressional representatives are under no such compunction.

Medicaid is currently the largest line item on the state’s budgets, threatening every other spending priority—Democrat or Republican. For the governors, containing Medicaid costs and reforming the program is a matter of survival—not partisan politics. Not surprisingly then, governors are the only ones offering any coherent strategy for Medicaid reform. In the meantime, we should treat all of the Medicaid rhetoric emanating from Washington with a very large helping of salt.

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Poisonings from a popular pain reliever are on the rise
The New York Times, 11-29-05

Editor’s Notes:

This article on accidental Tylenol (acetaminophen) overdoses is particularly interesting given last week’s Spotlight article from Derek Lowe, which pointed out that many familiar drugs that we think of as safe actually have serious side effect profiles.

The problem is that while the public is relentlessly focused on the threats posed by newer drugs like Vioxx and Celebrex, they forget that every drug, no matter how old and familiar, can turn deadly under the right circumstances.

Despite more than a decade's worth of research showing that taking too much of a popular pain reliever can ruin the liver, the number of severe, unintentional poisonings from the drug is on the rise, a new study reports. The drug, acetaminophen, is best known under the brand name Tylenol. But many consumers don't realize that it is also found in widely varying doses in several hundred common cold remedies and combination pain relievers.
These compounds include Excedrin, Midol Teen Formula, Theraflu, Alka-Seltzer Plus Cold Medicine, and NyQuil Cold and Flu, as well as other over-the-counter drugs and many prescription narcotics, like Vicodin and Percocet.

The authors of the study, which is appearing in the December issue of Hepatology, say the combination of acetaminophen's quiet ubiquity in over-the-counter remedies and its pairing with narcotics in potentially addictive drugs like Vicodin and Percocet can make it too easy for some patients to swallow much more than the maximum recommended dose inadvertently.
"It's extremely frustrating to see people come into the hospital who felt fine several days ago, but now need a new liver,'' said Dr. Tim Davern, one of the authors and a gastroenterologist with the liver transplant program of the University of California at San Francisco. ''Most had no idea that what they were taking could have that sort of effect."

The point here isn’t that Tylenol isn’t safe, or that Vioxx is, but that safety is always contextual—it depends on the drug, the patient’s condition, and how the treatment is used. “Safe” pills like aspirin can kill you, and horrible chemicals (like Cytoxan) are valued treatments for cancer and Lupus. Dangerous drugs aren’t deliberately produced by companies, who are just trying to produce the best treatments they can given the state of the science. Policymakers who routinely excoriate the FDA and industry for approving “dangerous” drugs should remember this and temper their rhetoric.

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AIDS Goal Missed, But Effort by U.N. Branch is Praised
The New York Times, 11-29-05

Editor’s Notes:

As Philip Stevens points out in this week’s Spotlight article, the World Health Organization will miss it’s goal of treating 3 million HIV+ patients with antiretroviral drugs (ARVs) by the end of 2005. Worse yet, the actual number of HIV infected patients has increased dramatically. Still, the WHO has done its best to broaden the scope of ARV treatment in Africa and elsewhere. Activists applaud their stated goal of reaching universal ARV treatment by 2010.

The World Health Organization's failure to meet a goal of treating three million H.I.V.-infected people by the end of this year owes to inadequate international coordination and lack of national leadership, a group of leading advocates for AIDS patients said yesterday.
Although the health agency has said it cannot meet the goal, the advocacy group, the International Treatment Preparedness Coalition, credited it with bold efforts.
The world agency has missed its goal by more than a million, and millions more infected people urgently need treatment, the group said in a report.

W.H.O., a Geneva-based United Nations agency, helped show that antiretroviral treatment can be delivered effectively, extending the lives of hundreds of thousands of people, even in the poorest settings, the coalition said.

Still, efforts by the United Nations and nongovernmental groups are unevenly coordinated and would benefit from a more pragmatic strategy to meet their goals in treating the tens of millions of people in need of antiretroviral therapy, the report said.

Crucial to that strategy is "a much more systematic approach to setting goals, measuring progress, and assessing and addressing barriers" to providing AIDS treatment, the report said.

Methodology aside, the bottom line question is whether the WHO approach is really the right one. Some critics—and we tend to count ourselves among them—question the opportunity costs of the “treatment-first” strategy. Getting ARV treatments to patients is a noble goal, but also an expensive, complicated, and time-consuming process. Every dollar spent on ARV drugs is a dollar not going to AIDS education, testing, and prevention programs. Of course, it would be ideal if we had an endless pool of money to spend on health infrastructure, drugs, testing, and prevention efforts. But we don’t and we won’t.

In the public relations department, however, the WHO’s goal has been a spectacular success. AIDS patients in Africa and other poor nations, however, will pay the real price if the WHO flubs its next incredibly optimistic goal over the coming five years.

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