Editor’s Note: This post was written by several of the 2007-08 Commonwealth Fund Harkness Fellows. These fellowships allow mid-career health services researchers and practitioners from Australia, Germany, the Netherlands, New Zealand, and the United Kingdom to spend up to 12 months in the United States, conducting original research and working with leading U.S. health policy experts. The lead authors of the post are Richard Gleave and Geraint Lewis. Additional authors include Kalipso Chalkidou, Andreas Gerber, Ruth McDonald, and Rhema Vaithianathan.
A recent article in the New York Times (“Paying Patients Test British Health Care System,” 21 February 2008) demonstrated a bias in the reporting of an international health care issue. The article focused on the case of a terminally ill woman in England who was prevented from paying privately for a high-cost cancer drug (Avastin) whilst she was being treated by the National Health Service (NHS).
The article broached three separate issues: (1) access to expensive drugs and technologies; (2) cost-effectiveness evaluation of new drugs and technologies; and (3) private top-up within public health care provision [supplementing publicly provided services with private services paid for out of pocket]. Each of these topics is relevant to the health care reform debate in the United States, but the way in which the article confounded the three distorted the issues.
Access to expensive health care technologies. The article insinuates that the patient fared worse in the U.K. than she would have done in the U.S., but this inference is not justified. Almost exactly two years earlier, the same newspaper published an article highlighting the difficulties that many Americans face in trying to obtain the exact same drug (“A Cancer Drug Shows Promise, at a Price That Many Can’t Pay,” 15 February 2006). This earlier article reported warnings from American doctors that “some cancer patients are already being priced out of the Avastin market … because out-of-pocket co-payments for the drug could easily run $10,000 to $20,000 a year.”
Money is a far more significant barrier to receiving health care in the U.S. than it is in the U.K. A survey by the Commonwealth Fund published in Health Affairs in November 2007, Toward Higher-Performance Health Systems: Adults’ Health Care Experiences in Seven Countries, reported that 37 percent of U.S. adults were hindered from accessing health care due to financial reasons, compared to 8 percent in the U.K. The survey showed that 50 percent of adults in the U.K. had no out-of-pocket expenses in the past year, compared to 10 percent in the U.S.
A recent Kaiser Family Foundation survey showed that a high proportion of Americans faced particular financial problems in having access to prescription medicines. It reported that three in ten (29%) say that in the last two years, they have not filled a prescription because of the cost, and nearly a quarter (23%) say they have cut pills in half or skipped doses in order to make a medication last longer. Four in ten report at least one of these three problems (a serious problem paying for drugs, not filling a prescription because of cost, and/or skipping doses in the past two years).
In contrast, another February 2008 survey found that only 2 percent of Britons said that they failed to fill a prescription because of copayments. Many Americans have insurance policies that require large copayments or that limit coverage for certain conditions and treatments. The Commonwealth Fund survey found that 30 percent of patients in the U.S. had expenses of over $1,000, compared with 4 percent of patients in the U.K. (the latter being patients who chose to have private rather than NHS treatment).
Of course, the problem of access is worst of all among the 80 million Americans who go without insurance coverage at some point during each year. No patients in the U.K. are precluded from accessing essential health care on the basis of cost, since the NHS provides comprehensive free universal care.
Cost-effectiveness evaluation of new technologies. The second issue that the article raised is how to make decisions about the coverage of high-cost new health technologies. Unlike the U.S., the U.K. has adopted an objective and systematic approach to making these decisions. In England and Wales, new medical technologies are referred to the National Institute for Health and Clinical Effectiveness (NICE), which makes decisions on whether they should be recommended for use in the NHS based on their cost per quality-adjusted life-year (QALY) compared to the next-best alternative. Technologies costing more than £30,000 per QALY are usually deemed to be unaffordable within the NHS. This threshold is far too low (i.e., leads to too many rejections) according the pharmaceutical industry, and it is too high according to a recent House of Commons multiparty Health Select Committee enquiry. While the NICE value threshold is a matter for debate and further research, the New York Times article presented no evidence about the cost-effectiveness of Avastin compared to other alternatives. Nor did it mention the concept of “opportunity cost” — what else could be bought with the money that would otherwise be spent on Avastin? And what would be the health benefit forgone for other patients who would have to go without treatment if Avastin (a technology of unproven value for money — we can say that much) was to be covered by the NHS?
Private top-up of public provision. The third issue tackled by the article is whether people should be allowed to pay privately to supplement publicly funded health care provision. Again, this is a genuine issue for debate. The U.K. rules about top-ups are currently inconsistent and complicated, and whilst we are not defending this state of affairs, we argue that there are no easy answers to this dilemma.
U.S. health care, a high priority is placed on choice of treatments and providers, so out-of-pocket top-up payments for specific drugs are the norm. However, even amongst insured Americans, many patients cannot afford to make such choices because the cost of copayments is so high. In England there are no deductibles, nor are there any copayments for visits, diagnostics, inpatient spells, or treatments. Adults in England pay a fixed £6.75 per prescription for drugs (approx. $13.50), whilst children, the elderly, the poor, and patients with certain chronic conditions are exempt from such payments. English adults can alternatively choose to prepay £98.70 (approx. $200) for a certificate that exempts them from all prescription copayments for a twelve-month period.
Last year, the NHS in Wales scrapped all copayments for prescriptions, and in Scotland ministers have committed to ending them within four years.
The NHS places a priority on treating patients equitably. In the U.K., patients are prioritized according to their level of need rather than on their ability to pay. By choosing to be treated by the NHS (as opposed to opting for private care — approximately 10 percent of the population), patients agree to accept NHS principles and its rules regarding equity and efficiency. Top-up out-of-pocket payments conflict with the principle of equity because they create perverse priorities. Until recently, for example, waiting times for magnetic resonance imaging (MRI) for nonurgent conditions were often very long in the NHS. At first glance, it would seem reasonable to allow NHS patients the option of choosing to pay privately for an MRI scan to avoid a long wait. A problem arises, however, when these patients take back the results of their scan to the NHS. With their MRI results in hand, such patients could obtain an NHS operation earlier than patients who did not pay for an MRI. In other words, the patients who pay are being prioritized for an NHS operation not on the basis of urgency or necessity, but simply on their ability and willingness to pay for an MRI.
Another concern is that allowing top-ups will result in inflated prices across the board, by crowding out “essential” treatments from the core NHS package and by making top-ups the norm rather than the exception. This might risk transforming the NHS from a universal national health care system to a safety net for the poor — a transformation that British society apparently does not wish to make: According to an annual national survey, more than three-quarters of the British public believe that “the NHS is crucial to British society and [we] must do everything to maintain it.”
Other countries with universal health care have approached this same problem differently. For example, in New Zealand, patients face no restrictions on topping-up public provision with private care if they wish to have quicker access than provided by the public system. A patient in New Zealand can see a specialist for an initial private out patient appointment, then be put on the public waiting list for a diagnostic procedure or operation, and then return to specialist afterwards. Whilst this does undermine equity, the costs involved are fairly minimal. Also, if the person is a beneficiary (e.g., receives disability benefit or is a solo parent), he or she can ask for a top-up from the benefit system for the extra medical expenditure.
The issue of top-ups is unresolved and contentious in many countries that have universal health care. We would urge the media to address this dilemma head-on rather than clouding it with other issues.