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Author Topic: US Hates NICE
kenmeer livermaile
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Why do we need commercials to diagnose our ills for us? YOu want blue skies smiling on you? Ask your doctor about... and may the best placebo effect win.

There are enough horrid illnesses and syndromes (I have one, thank you very much) going around to provide pharm research with lots of profit-motivated opportunities for another century or three, I'm sure.

I'm all for profits, and for folks attaining wealth by such efforts, but the *maximization* of profit as a driving criteria is what produces those horrors that give capitalism's many smiling faces a black eye.

A bit of restraint goes a long way in ANY goddamed economic system.

[ November 16, 2006, 12:12 PM: Message edited by: kenmeer livermaile ]

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kenmeer livermaile
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Why does the awful specter and reality of guvment regulation exist? Because, absent reguations, the impulse to maximize profits (some call it greed) becomes extreme and next thing you know you have mass coolie graves alng the Union Pacific railway line...

[ November 16, 2006, 12:14 PM: Message edited by: kenmeer livermaile ]

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Tom Curtis
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quote:
Do you want a Government, or your Doctor, to decide if a therapy is "worth it"?
When the government is paying for the therapy, as is the case in England, it's the governments call.

The notion that the government should not makes its best judgement regarding the efficacy and relative cost of drugs it will subsidise for its citizens is ridiculous. Who pays the piper calls the tune. So in practise, demands that NICE stop its gatekeeper role come down to requiring an open ended subsidy on health without regard to effectiveness of medication, or an end to subsidising health costs. The first is not feasible; the second abhorent. (There is the reason the US gets the worst health outcomes for price in the Western World.)

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The Drake
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When the government is paying for the therapy, as is the case in England, it's the governments call.

I wonder how many people would accept that statement when written:

When the HMO is paying for the therapy, it's the HMO's call.

HMOs get beat-up all the time for denying payments for experimental therapies and drugs. But if a government agency does the denying, they are looking out for the best interests of patients?

A panel of doctors is not my doctor, and I can't change those doctors on the panel if I don't like the job they are doing. I can change my personal physician.

An HMO is not easy to change under the current system of insurance (too bad), but at least it has competitors.

I think it is important to note that NICE is not saying that this drug is ineffective, merely that they haven't seen it proven to be more effective.

Where should the burden of proof be? And even if the nice lady has bought into a placebo effect - if it makes her feel better, who gives a damn if studies show the drug to be only marginally more effective?


patient and personal physician and drug company

v.

government panel of doctors and accountants


Choose your Side.

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Jesse
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The people paying the bills get to decide, Drake.

Should the US pressure Blair to change the UKs strict gun laws so that Colt can increase worldwide sales?

Should the Dutch pressure us to stop banning marijuana so that they can export to us?

This isn't about the health of the British consumer of health care, it's about turning Pounds into Dollars. It's not about whether "Doctors and Patients get to decide...". The UK isn't going to abandon NHC anytime soon, and as long as they have it the dreaded government functionaries are going to be making decisions about health care.

The question isn't "does the US have the right?" but rather "Is it right?".

This isn't how we ought to be treating one of our closest allies, that's for damn sure. If there is such demand for these drugs in the UK, they can use a neat little thing called the Democratic Process to try to get their NHC system to pay for them.

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kenmeer livermaile
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The STOCKHOLDERS of an HMO have direct input regarding the choosong of who makes policies for an HMO. THey elect the representatives. The patients vote with their wallets in a market place of diminishing choices.

In government-subsidized health provisions, the PEOPLE have direct input regarding the choosing of who makes policies regarding health treatments.

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Ivan
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I think there's one issue that's largely been overlooked here: Deputy Health Secretary Azar's (the guy in the article linked in the OP) problem is not with tariffs or that Britain is not allowing drug companies to export their product to GB. His problem is that the drugs are not being covered by Britain's national healthcare program; individuals are free to purchase the drugs on their own or purchase supplementary health coverage (which some do!) that will cover these drugs. What NICE does is not decide whether drugs are safe. What they do is decide whether it is cost-effective to use certain drugs as opposed to other treatments. NICE determines how effective various proceedures (or medications) are at increasing Quality-Adjusted Life Years (link for more information on QALYs) per cost. Based on this criteria (and other factors), they choose to either approve the proceedure for coverage by the NHS or not. In the case of the drugs in question, they are simply not cost-effective treatments, either becuase the prices of the drugs are too high, the value of their benefit is too low, or the side-effects cause too much additional cost (or some combination thereof). The US doesn't want a trade agreement; we want to change the way their national health care system works:

quote:
[Azar] also wanted to share the US experience of offering private insurance packages to people on Medicare - the healthcare scheme provided by the government to the poor and elderly. It might be possible for the UK government to consider something similar, he suggested, so that everyone could choose either a basic healthcare deal or top it up themselves if they wanted to pay for more than the state could afford.
This has nothing to do with international free markets and everything to do with drug companies using the US government to pressure a foreign government into creating a more favorable domestic environment for them to trade in.


In other news, I wrote my thesis on direct-to-consumer advertising, so I figured I might throw in a few thoughts about it.

First off, it is clear that drug companies advertise to expand their markets rather than to "steal" marketshare from eachother (which is what advertisement in other markets, such as Soda, is generally accepted to do).

In addition to that, DTC advertising is generally very effective at expanding these markets. Why exactly this is is certainly open to debate. There is a wealth of anecdotal evidence that physicians feel pressure to conform their patient's wishes. If a patient comes in expecting to recieve a prescription, many physicians feel like they'd better give it to them lest their patient leave and go to another doctor. (One could argue that in these cases, the physician could simply prescribe a placebo, but that's neither here nor there.) However, there is little evidence suggesting that physicians fear prescribing a drug different from the one a patient requested (eg., Allegra instead of Claritin) if such a drug is required.

In the end, however, the "company line" from drug companies on this regard is pretty close to the truth: DTCA really does get the word out about new, innovative drugs. People with chronic conditions (like seasonal allergy or arthritis or whatever) are used to living with these conditions, and when something comes along out of the blue (like Celebrex or Claritin or whatever), people's lives get better faster because of DTCA.

It's also worth noting that there is evidence that the drugs that are most heavily advertised are usually the ones for which the untaped market (ie, people who are indicated for the drug but haven't had it prescribed) are the greatest. Similarly, once this "potential market" is close to being tapped out, the advertisement abates.

Anyhow, I really think that DTCA is overall a good thing. Sure, over-prescription happens because of it and some people who really don't need medication end up getting another set of pills to take. But the net effect is distinctly positive. And lets remember that there's still a licensed physician who has to put his or her name down that the medication is appropriate, so gross mis-prescription should only happen when we have a very negligent physician, and such a case, the problem really isn't with the advertising. [Smile]


ETA something that I should have included but forgot to. Stupid brain.

[ November 16, 2006, 05:22 PM: Message edited by: Ivan ]

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kenmeer livermaile
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"There is a wealth of anecdotal evidence that physicians feel pressure to conform their patient's wishes. If a patient comes in expecting to recieve a prescription, many physicians feel like they'd better give it to them lest their patient leave and go to another doctor."

etymology of placebo:

"c.1225, name given to the rite of Vespers of the Office of the Dead, so called from the opening of the first antiphon, "I will please the Lord in the land of the living" (Psalm cxiv:9), from L. placebo "I shall please," future indic. of placere "to please" (see please). Medical sense is first recorded 1785, "a medicine given more to please than to benefit the patient."

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The Drake
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Quite right, Ivan, I had mixed up trade and purchase authorization. And it nullifies some of my arguments, naturally.

But since NHS is the only game in town (a monopoly?), I can still understand the motivation.

quote:
It might be possible for the UK government to consider something similar, he suggested, so that everyone could choose either a basic healthcare deal or top it up themselves if they wanted to pay for more than the state could afford.
Now, what's wrong with that plan, actually? If the cost to the NHS for drug A and drug B are the same, but the patient wants expensive drug B, why shouldn't they be able to upgrade for themselves? How is that controlling government cost, by paying nothing for drug B?

Kenmeer:

I guess stockholders aren't people? If the profit motive and the bureaucratic motive yield the same action (denying payment for an expensive new drug), can one really be called better than the other?

Jesse:

I might agree with you, if we actually made some kind of a threat to the UK. All we did is make a statement that we think they ought not do what they're doing. It's not like the UK doesn't try to pressure the US to drop the death penalty - going well beyond just making statements, as they refuse to extradite criminals according to treaty. But by and large we have only a few points on which we disagree.

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Cytania
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"I can't change those doctors on the panel if I don't like the job they are doing. I can change my personal physician."

So I went to the hardware store and they wouldn't sell me a chainsaw without boots, gauntlets, chaps, guard etc. So I went to another store who just sold me the chainsaw. Job done (it's real slow tying this one-handed though).

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Ivan
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Drake- The thing is, private providers are able to offer services and such; most peopel just aren't able to afford it. It's not a monopoly as much as it is free and therefore much cheaper than everything else. Also, why should Britain want a system more similar to the US? They have similar health outcomes to people here, and their system is cheaper than ours.

Actually, NICE and the NHS are things I think we should model our national health system on. The economies of scale that come into play when you're dealing with hundreds of millions of individuals make such a difference that privat providers are simply priced out; a national system is just cheaper. And numerous other countries (I've read some stuff about Germany and Australia, as well) have systems similar to GB, whereby services deemed "cost-effective" are provided free by the government while others are up to individuals to purchase themselves. In such systems, treatments that cost less than $20,000-$40,000/QALY are general covered by the government but those that cost more are generally not. What this amounts to is the most effective treatments are provided for everyone and costs are controlled. Individuals with the wealth to purchase other types of coverage are allowed to do so at their own expense (or by purchasing additional private coverage). It's the best of both worlds.

The only controversy is in deciding which treatment options are "cost effective" and the like, and how much you trust the empirical results for that depends on how much you trust QALYs as a robust tool for measuring health state preference. While there are certainly still some kinks that need to be worked out of the system, they're becoming more and more accurate. As more studies continue to be added to the literature, we'll eventually reach the point where health state utility measures can accurately define the value (in QALYs) of every medical option out there.

Anyhow, this is the direction that health economics is moving in, so the better you understand it, the better you'll understand the way your healthcare is decided in 20 years time.

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The Drake
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When you talk about healthcare being cheaper, you have to also ask "What was the money being used for?"

If nationalizing an industry really made things cheaper for consumers with no inherent problems, then why limit it to health care?

Instead, we've seen that nationalized industries lack innovation. That's my biggest beef with nationalizing health care, and the suspicion that the cheapness of other systems is because the USA is subsidizing that innovation for other nations.

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DonaldD
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quote:
If nationalizing an industry really made things cheaper for consumers with no inherent problems, then why limit it to health care?
Is the delivery of healthcare different than, say, the manufacture of automobiles? Neither nationalization nor privatization is a panacea.

BTW, how is the USA subsidizing the delivery of health care in other nations?

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kenmeer livermaile
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Hesalthcare is way different than any other industry. It is in many ways more like religion.

It is a puzzle all its own.

There's a reason much of Europe has socialized medicine but not socialized automobile manufacture/sales/maintenance.

(There's also a reason why insurance companies increasingly own de facto the practice of medicine, but one tangent is enough for today for me.)

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Daruma28
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quote:
Originally posted by Cytania:
"I can't change those doctors on the panel if I don't like the job they are doing. I can change my personal physician."

So I went to the hardware store and they wouldn't sell me a chainsaw without boots, gauntlets, chaps, guard etc. So I went to another store who just sold me the chainsaw. Job done (it's real slow tying this one-handed though).

In other words, you are saying that if the Government doesn't tell you what safety precautions to take, you are too stupid to figure out how to use a chainsaw without cutting your own hand off?

Good. Than you deserve to be one handed. [Razz]

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javelin
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Or at least, you won't be using a chainsaw like an idiot again. [Wink]
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kenmeer livermaile
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"Or at least, you won't be using a chainsaw like an idiot again"

Oh. I thought you were talking about me when I first saw this sentence. Shotguns DO work better, I note.

How stupid IS too stupid? (For example, do we the people deserve to have our reputation buried in Iraq because we were too stupid? DO we deserve to have the brakes on entering war, as originally written in the Constitution, returned, so that Cngressional oversight actually means something, again, other than a political litmus test for public opinion?)

But, back in the medical realm: do we need to be protercted from our folly? If Joe Go wants to rce around town at high motorcycle speeds without a helmet, how wise are we to require helmet laws so our society doesn't bear the cost of keeping motorcycle brain-vegetable patients alive? (Whether or not they can wink yes or no when we ask them, "Are you Terri Schiavo?")

Does someone buying their first chainsaw, who's never felt one kick back and try to bite their hand or leg off, deserve to be legally restrained from committing a folly that could devastate their family?

IS it unreasonable to require that gun purchasers take a course in gun safety before they use one? (Hint: the Army certainly thinks so, although we must replace the word 'purchaser' with 'recipient of government issue'.)

Someone bruns themselves in a McDonalds with hot coffee, and a sharp lawyers gets the brass ring damages reward on their nehalf, and we suddenly find it foolish to require that society be protected from the damage it receives, however indirectly, from the dangers of our folly or ignorance?

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The Drake
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quote:
So I went to the hardware store and they wouldn't sell me a chainsaw without boots, gauntlets, chaps, guard etc. So I went to another store who just sold me the chainsaw. Job done (it's real slow tying this one-handed though).
Flipside to every story. What if I already have boots, etc? And I go to the store, and they won't let me have a chainsaw?

I don't want to wind up with a least-common-denominator society.

In medical terms, this means that I should get to research whether a drug is worth it, whether a treatment is appropriate, if I need to see a specialist, etc.

Now, I've got no problems with a two-tier system - the cheap, long lines, basic healthcare AND the pay for it yourself option. But you should still get to apply what you would have got for the free choice to the premium choice.

If the government were to offer me $5 toward the purchase of drug A, they shouldn't begrudge me the same $5 toward the purchase of drug B. We have the same problem with elder care, where the government will give you money for a rathole facility, but if you want a private facility, you won't get a dime.

[ November 17, 2006, 03:30 PM: Message edited by: The Drake ]

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kenmeer livermaile
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"Flipside to every story. What if I already have boots, etc? And I go to the store, and they won't let me have a chainsaw?"

I would think that the sensible medium would be for the customer to sign opff on a waiver that they understand tha use of a chainsaw without x,y,z could result in loss of life, limb, libido [Wink] .

IN courst cases regarding insurance/welfare compensation for cutting off one's hand, such waivers might prove influyential. WHo knows? We DO liuve under Rule of Law; in fact, it is Rule of Law that guarantees our essential freedoms.

Weird world.

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Tom Curtis
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The Drake:

quote:
I guess stockholders aren't people? If the profit motive and the bureaucratic motive yield the same action (denying payment for an expensive new drug), can one really be called better than the other?
The difference between a company director (ie, those who actually make the decisions) and a bureaucrat is that the bureaucrat is under pressure to keep the program in budget; the director is under pressure to reduce costs or increase charges as much as is humanly feasible in order to maximise the difference between the two. Consequently, the director is more likely to impose cost cuttings that result in real harm to patients.

quote:
When you talk about healthcare being cheaper, you have to also ask "What was the money being used for?"

If nationalizing an industry really made things cheaper for consumers with no inherent problems, then why limit it to health care?

The effectiveness of free markets in delivering goods depends essentially on there being low transaction costs, low negative externalities, and on all parties of a transaction being effectively informed about costs and benefits. In the pharmaceutical market you have three main players, the corporation providing the product, the doctor who is informed but who is not primarilly motivated by patient health outcomes, and the patient who is typically completly uninformed about the products and effects. If the corporation can provide direct or indirect financial benefits to the doctors for following a particular prescription strategy (and they can), this is a recipe for market failure in the form excessive costs to patients.

That is a key difference between the health market and the automobile market.

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Ivan
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Drake-

I disagree that innovation will be adversely effected by nationalizing our healthcare. Moreover, I haven't seen anything to suggest that our system encourages innovation (which is a pretty ambiguous term in this context) more than, say, Britain's or Germany's.... But leaving that aside:

If we do adopt a system similar to NICE, "competition" will still exist. It will take place in the studies that are done to determine which proceedures give the best return, the most "health" for the buck. If new proceedures come along that are cheaper or give better outcomes (or both), they will displace older proceedures. New medications which beat out older ones if they have fewer side effects or are easier to produce, etc.

As long as we have a good metric for quantify this stuff (and I believe that QALYs are getting there), we'll be able to create a more cost-effective healthcare system.

As for "What was the money being used for?", a simple answer might be that it was being used to pay for proceedures that had relatively poor cost-effectiveness. So while individuals without insurance are not recieving treatments that could be very beneficial to them and cost relatively little, individuals with good health insurance are being splurged upon, recieving treatments that are costly and have little likelyhood of gain.

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The Drake
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See, I could get on board with any of these statements - if there were simply one government managed area that looked cost-effective.

Instead, I look at defense contractors, public works contractors, the space agency.

In all of these cases, all I hear about are cost overruns, kickbacks, contracts to the lowest bidder. Or, I hear about no-bid contracts, mysteriously linked to family members and college buddies.

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LetterRip
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The Drake,

quote:
f there were simply one government managed area that looked cost-effective.
Veterans Administration.

LetterRip

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The Drake
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So, does that imply that we should all go to VA hospitals? Because I've heard there were lots of problems with them. Maybe not recently, however.
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javelin
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My mother recently had a pinched nerve. She's been in pain for over three weeks - to the point where she couldn't run errands. This is a woman who would teach a class of third graders all day, come home and make dinner, and clean the house - all with a migraine that would make most people hide in their rooms with the lights off and all the medication they could fine.

The VA told her doctor that they wouldn't approve an MRI when the normal treatment methods didn't deal with the pinched nerve. She's had to pay, out of her own (retired) pocket for chiropractor sessions so she could use her arm. She's still in pain, but it's not crippling. The chiropractor is still attempting to find a way to get the MRI paid for (I think paying for one herself would cost something like $1000), because he's unsure how to treat her further, and has been concerned about causing damage due to not knowing where the problem is, exactly.

This is the Veteran's Administration's idea of a good medical plan. Nice one, LR.

[ November 18, 2006, 08:32 PM: Message edited by: javelin ]

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Everard
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Nice misrepresentation of what LR said, jav.
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The Drake
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Well, LR has suggested that the VA controls cost well. Jav has pointed out one of the ways they do that. How is that a misrepresentation of anything?
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Everard
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Cost effective is not the same thing as "provides good service." It means "costs are proportional to the service provided," or a similar translation.

Javelin is saying "My mother got bad service, so therefore LR is wrong to say "the va is cost effective."

Its either bad logic, or misrepresentation.

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javelin
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It isn't "cost-effective" if it isn't effective. Misrepresentation? More like miscommunication. Ultimatums are silly - it's rarely one thing or another.
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Everard
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Whatever. You keep doing what you do, ornerymod.
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kenmeer livermaile
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Whatever. You keep doing what you do, evermad.
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Tom Curtis
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What ultimatum?
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LetterRip
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javelin,

the question was cost effective, don't recall where I read it but apparently the VA provides superior service at a lower cost than commercial benefits of the same level. Whether an overall higher service level is desirable is unrelated to the question at hand.

LetterRip

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kenmeer livermaile
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Denying use of requisite diagnostic tools in order to treat a crippling illness is one way of being cost-effective, I suppose. For that matter, letting patients die might be cost-saving, too -- presuming your attornies kick ass.

"She's been in pain for over three weeks - to the point where she couldn't run errands. This is a woman who would teach a class of third graders all day, come home and make dinner, and clean the house - all with a migraine that would make most people hide in their rooms with the lights off and all the medication they could fine."

In my personal subjective biased opinion, there's nothing tougher than a tough broad.

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The Drake
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I disagree. It is quite relevant. It directly contradicts the claim that the VA provides superior service. It is far from conclusive since it is anecdotal.

The VA could be a great model to better understand the options, if we can focus on bringing more information to the discussion. Thanks to LetterRip for suggesting it.

[ November 18, 2006, 11:20 PM: Message edited by: The Drake ]

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javelin
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I guess I'd call that "cost saving", not "effective". Guess it depends on the way you mean the term, really. As I said, quite possibly a miscommunication. It happens.
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LetterRip
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The Drake,

here is one paper comparing VA versus a national sample of patients,

http://www.annals.org/cgi/reprint/141/12/938.pdf

Will look for more info when I have time...

LetterRip

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The Drake
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Thanks, I'll definitely read that. Also, it is worth pointing out that there are many documented cases of HMO, PPO and other private managed care plans denying medical tests as well.
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Ivan
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Interstingly, I did provide an example of a government-run agencies that were able to provide a service: the NHS! [Big Grin] No one ever said it had to be an American system. [Wink]

Another reason that we should be willing to try this with medicine even if other bureacracies have failed in the past is that medicine is not simply business: it's very directly life-or-death for many, many people. Unfairness in healthcare ration results in some people dying while others live, and on a much greater scale than rationing, say, safty features in automobiles.

Healthcare has gotten to the point where far more is available than we can afford (as a country) to provide. As we are seeing with the Medicaid drug benefit, the public is unwilling to accept that some people can get life-saving medication (or treatment) while others can't. The outcry for more fairness in medicine is taking the form of very, very expensive government programs that more or less fail to ration. Price rationing (people with more money get more/better insurance/treatment, etc.) has lead us down this road, and the only way to get off it is to find a different way to ration.

I recommend the scientific approach that NICE and other nations are trying to use, and frankly it seems like the only reasonable alternative. Since this is America, we'll definitely have some price rationing thrown in (preferably only at the higher levels of coverage [Wink] ), but I don't necessarily think that's a bad thing.

Broad summation: Things have to change becuase that's what people are voting for; cost-effectiveness rationing is the best way to go.

[ November 19, 2006, 01:30 PM: Message edited by: Ivan ]

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The Drake
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I realize that I'm doing something that I regularly criticize politicians for doing -tearing down a plan without having one of my own. I picked up a couple of books today on the healthcare situation. I hope to come up with something better than the LCD healthcare rationing offered by a national health service. If I can't, well Any plan is better than No plan.
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