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:
Detsky & Naglie. A clinician’s guide to cost-effectiveness analysis. Ann Intern Med. 1990 Jul 15;113(2):147-54.
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!”
oh yes there is – got down on the defense budge and put more in healthcare.Who needs a nuke anyways!
But this ignores the argument that an expensive early treatment is more cost effective over the patient's lifetime. Furthermore, wouldn't alemtuzumab, which might be administered twice every 5 years or more or stem cell transplantation ultimately prove less expensive than an ongoing prescription for Copaxone or Tysabri?
It is so short sighted not to support people to stay active and in work and caring for themselves and their families as well as part of wider society (volunteering as part of the Big Society?) by failing to fund these treatments after the 1st or 2nd attack, rather than to wait. then there is the aspect of human decency and enabling people to have as good a health as possible.
In the US, my insurance through my employer provided my access to copaxone. I was on it two months after being diagnosed. Maybe some people who have delayed taking DMTs simply ignore the reality of their condition.We provide healthcare in the US already,but some refuse to take tesponsbility.
"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 would suggest that you neurologists seek some sort of meeting with the powers that be at NICE and lay out the facts that the earlier MS is treated the more cost-effective it is.There also needs to be some home truths conveyed to pharma that they need to reduce their prices if they want to see their drugs prescribed. At the moment there is no competition as a free market would predict, rather the market operates as anti-competitive cartel.
"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."There is only one study to support these mortality data, made by Bayer, the Betaferon manufacturer. You always say that results should be replicated by different researchers, especially if there are huge conflicts of interest, as in this case. So, according to you, we shouldn't take these results for granted.
Mr. Vasilis,I sent you an email. Hope if you could answer me.Thanks in advance.URBA.
Re: "So, according to you, we shouldn't take these results for granted."Yep, we shouldn't take them for granted. But the Biogen-Idec 15-year Avonex data that have been presented show the same thing. I am sure they will be coming out shortly in a peer-reviewed journal. The good thing about science is that robust findings get reproduced; this is not something that happens in all areas of MS research. I can think of a very notable example.
"i sent you an email"Nice for everyone to know. Hope we are not becomming a dating service:-)
"Hope we are not becomming a dating service:-)"With so many young intelligent women (& presumably attractive) being diagnosed in their 20-30 I suspect we would rather become a classy dating service if there were one on offer :-))
"But the Biogen-Idec 15-year Avonex data that have been presented show the same thing."Are you talking about the ASSURANCE study?Even if there are such data, they are the product of a major pharma company with insurmountable conflicts of interest.If independent researchers could reach the same conclusions, then we would have something credible.
VVIf independent researchers had hundreds of millions of dollars, they would do the trials, but they don't, so they can't.Yes, these trials are sponsored by big pharma but sometimes you have to trust the integrity of the medics who carry out the trials.It's not ideal, I agree but it's the best we've got.I suspect though that if independent researchers reached the same conclusions, you still wouldn't find them credible 😉
MD2, i don't think you need millions to do a cohort study about morbidity. The Canadian research about the long term lack of efficacy of INF-b was such an independent study.
VV the Canadian study could have done with millions; that is what it costs to get rid of biases.
The canadian research was a independent study, but how much did this cost to support the researchers over the years of collecting dataFurthermore do you think that none of the resesearchers or their Universities have ever recieved funds for doing beta intereferon studies?
Considering that British scientists were responsible for monoclonal antibodies and alemtuzumab it will be ironic and sad if patients in Britain don't get easy access to it
The two As from Cambridge need to lobby Genzymne to make sure they do not charge too much.
Science made my drug industry money is not science, it is industry 🙂 New canadian research showed real effect with interferons in MS, which is zero, it doesnt slow the disease. Maybe minor effect with relapses, but nothing in long run with disease. Research should focus now to new directions.
Re New Canadian Research….zeroPlease read the blog.http://multiple-sclerosis-research.blogspot.co.uk/2012/07/research-beta-interferon-and-progression.htmlYou have made one intepretation there are others…such as Prof Gs.Research, besides the clinical studies that add fluff for Pharma, have never really focussed on interferons because they do not and did not react with any species besides humans. Beta interferon was a suck-it and see approach vailed in an anti-viral idea. Research now is much more focused on mechanism led approaches.
Science made by drug money is not science…Yes it is…but is it bad science:-)Without industry support alot of MS science would not get done…including the blue sky science
Re: "Science made my drug industry money is not science, it is industry 🙂 New canadian research showed real effect with interferons in MS, which is zero, it doesnt slow the disease. Maybe minor effect with relapses, but nothing in long run with disease. Research should focus now to new directions."Simply not true; some of the brightest and best scientists work in industry. Where do you think effective therapies come from? Most academic institutions have deskilled themselves when it comes to drug discovery; we don't have medicinal chemists or the high-throughput screening platforms that are necessary to find drugs and then optimise them. By the way the Canadian Study is one of many so you can't look at it in isolation. As I have already pointed out it is an observational study with a lot of built in biases. As a result I doubt very much if it is going to have an impact on the prescribing of DMTs.