What drugs do we pay for? You decide

Over the past couple of years controversy has flared on a number of occasions over whether the State should or should not pay for newly available drugs or treatments that offer major advances for patients but come at an extremely high price.

In a number of cases, the Government intervened and ensured that new drugs were made available, for example, to patients with particular types of cancer or cystic fibrosis despite the products having failed cost-effectiveness tests.

It is inevitable that patients with a particular condition along with their families and friends would argue strongly that newly developed treatments or drugs that offer greater potential should be available in the public health service.

However, on the other hand, the costs involved can be extremely high at a time of already stretched health budgets.

Last year, for example, it emerged that one cancer drug, with a price tag of around €74,000 for an 18-month course of treatment, could cost the health service about €39 million over five years to treat 130 patients.

It is generally agreed in the health service that these arguments will continue and probably intensify in the years ahead as more drugs and treatments emerge with very high costs.

Set of values
The draft white paper on universal health insurance, drawn up by the Minister for Health, James Reilly, proposes that as a society we should prepare for this eventuality and lay down a set of values that would underpin decisions in this area in the future.

Perhaps the key issue in the whole plan for universal health insurance is what should be contained in the standard health basket – the package of services for which everyone in the country will have to be insured.

The draft white paper says that decisions on the composition of the future health basket are not simple or straightforward.

“Rather, they are complex and multi-faceted, involving various technical, economic and ethical considerations.”

Above all, the draft white paper asserts, “they are deeply value-laden”.

"And, as such it is very important that the values underpinning the health basket reflect the values of the society served by that health basket."

Establish a commission
But what are the core values of our rapidly changing society and how should they be determined as they affect healthcare?

The document says that the Government would establish a commission to engage extensively with the public before finally making recommendations to Ministers on what should be contained in the standard health basket.

It says that as part of the consultation process, the new commission would develop a “values framework” that would embrace the ethical, economic and technical issues and which would be used in assessing health services and technologies.

The draft white paper puts forward its own illustrative values framework – essentially a series of questions – “as a starting point to aid the development process and stimulate collective deliberation and public debate”.

While some of these questions such as asking whether treatments, services or technologies are safe or achieve the desired outcomes are relatively non-contentious, others would undoubtedly prove to be hugely controversial.

For example, the draft document poses the question as to whether a treatment, service or technology was “essential” and how this should be defined.

“Should all life-saving treatments be considered essential or should quality of life and life expectancy be taken into account when considering whether life-saving treatments are essential.”

Specifically it asks whether any service, technology or treatment would have to demonstrate substantial health gains or years of life gains in order to be considered essential.

“Are services which are palliative rather than curative essential and how do we prioritise between two different types of services?

“In addition to concepts of ‘life-saving’ and ‘health improving’, should the concept of ‘maintaining human dignity’ be factored into considerations of which services are deemed essential?”

The draft document also raises the issue of treatments provided for religious or lifestyle reasons. It asks whether circumcisions or services to remove tattoos should be considered essential.

Perhaps more controversially the draft white paper questions how or whether as a society we should consider the resource implications of providing particular treatments or services on the health system or even the whole economy.

“What is the opportunity cost of a decision to fund this treatment? Could the money be spent to better effect on other health services, on other public services or private consumption, ie what is the net welfare benefit relative to other policy options?

“Is it fair to share this cost at a societal level or should some costs be a matter for personal responsibility?”

Senior Government figures said last week that up to now decisions on issues such as these have been determined behind closed doors. However, with the move to a new model of healthcare provision, it was felt that a broader public view should be canvassed.

Fascinating debate
The likelihood of consensus emerging around many of these questions may be remote, but the debate on the values we wish to underpin our healthcare system of the future should prove fascinating.