I have just reviewed an article that systematically reviewed all the publications that have assessed the cost-effectiveness of DMTs in MS. The paper raised an important issue of the conflict that exists between neurologists (prescribers) and payers and quoted this paper:
Cost-effectiveness analysis can be used to help set priorities for funding health care programs. For each intervention, the costs and clinical outcomes associated with that strategy must be compared with an alternate strategy for treating the same patients. If an intervention results in improved outcomes but also costs more, the incremental cost per incremental unit of clinical outcome should be calculated. The incremental cost-effectiveness ratios for various programs can be ranked to set funding priorities. By using this list, the person responsible for allocating resources can maximize the net health benefit for a target population derived from a fixed budget. Clinicians may not share this objective because, individually, they are appropriately concerned solely with the effectiveness of a specific intervention for their patients and are not concerned with the benefit derived from spending those resources on other patients in the target population. In addition, allocation may be driven by distributional and political objectives. Nevertheless, cost-effectiveness analysis demonstrates the consequences of allocation decisions. Because clinicians should participate in policy making, they must understand d the role of this technique in setting funding priorities.
“The conflict between commissioners/payer and neurologists is an important one and is getting more hostile as more effective DMTs emerge that cost substantially more. I envisage these treatments being increasingly targeted, by NICE, to smaller groups of highly-selected MSers as third or fourth line treatments. This makes a mockery of the trial results that show that a wider groups of MSers are likely to benefit than simply the more active MSers. It also does not take into account the lost ground that will inevitably occur by waiting for MSers to fail first, second and possibly third-line DMTs.”
“The lost-ground phenomenon is real and is well illustrated with the existing DMTs. You cannot get back the time you have lost by delaying starting DMTs. The 21-year mortality data showed that in the placebo-treated MSers who went onto IFNbeta 3 years later, than the actively treated MSers, never caught up. If you have active MS (relapsing) and delay treatment by 3 years you are were more likely to die than the MSers starting DMTs 3 years earlier.”
“How do we as a community prevent NICE and payers restricting, or delaying, access to more effective therapies for MSers with active disease? How do we prevent MSers losing ground by delaying access to effective treatments?”
“I suspect in fee-for-service healthcare systems, for example the USA, money talks, if you can afford it you get it. This is fine if you are wealthy, but what about the uninsured MSer who can’t afford the treatment? In comparison, socialist countries treat healthcare as a basic human right; all of their citizens have equal access to healthcare. However, this comes at a price; rationing to make the system affordable to all. Rationing may be fine at a population level, but it often lets the individual down.”
“I hope you understand the conflict that is emerging? There are no easy options or solutions!”