Rational Rationing

Full disclosure: I stole that headline from an article on Pharmalot that triggered this blog. It reported on a New York Times op-ed piece by doctors at Memorial Sloan-Kettering Cancer Center in New York City about why the hospital won’t use the newly approved drug for metastatic colorectal cancer, Zaltrap.

Their reason? The drug is not any better than the currently used treatment, Avastin, and it costs more than twice as much, about $11,000 for a month of treatment.

Rational? Yes. Rationing? No.

It’s not rationing because patients can always go to another hospital and get the drug, which I know they’ll do because in this country we believe “new” is always better in medicine.

I saw this in action when I was a newspaper reporter (remember newspapers? You held them in your hands and got ink on your fingers?). Back in the day, I covered the “bone marrow transplant” story. This was when women with breast cancer demanded  bone marrow transplants even though there was no evidence that this highly toxic, highly dangerous, extremely expensive approach worked. Since the procedure was considered investigative, their insurance companies refused to pay for it. The women sued insurance companies, went to the media, held fundraisers and got their bone marrow transplants.

And many of them died. Not from the cancer; but from the transplant.

In the end, a large,  randomized trial showed conclusively that women who got stem cell transplants didn’t survive any longer than women who received usual treatment, and the issue faded away.

I can see the same thing happening with Zaltrap.

So how did Zaltrap get on the market if it’s no better than existing options? As the NYT article noted, the FDA doesn’t consider cost in its decisions, only if a drug is “safe and effective.” And Zaltrep is (well, as safe and effective as a poisonous cancer drug can be).

When are we going to wake up and talk about the elephant in the room—the cost of the fancy procedures we do and the expensive drugs we use, some of which are no better than older, less expensive options. New is not always better, people. More is not always best.

They know this in the United Kingdom and other European countries, where they confront the elephant every time a new drug is approved. The European version of the FDA, the European Medicines Agency, approves the drug based on safety and effectiveness but then country-wide organizations, like the National Institute for Health and Clinical Excellence (NICE), determines if the drug will be available on its national formulary. It bases its  decision not only on clinical effectiveness and safety, but on cost effectiveness. If NICE decides a procedure or drug is not cost effective (based on a formula that determines the cost per quality year of life), you can still get the drug or procedure; but the national health system, which covers everyone in the country (imagine that!), won’t pay for it.

For instance, NICE doesn’t pay for epidural steroid injections, the same procedure that’s been in the news after dozens of people developed fungal meningitis from a contaminated steroid. Forget the contaminated drug for a minute; there’s also “no strong evidence for or against” the injections. In other words, we don’t even know that it works any better than conservative treatments for back pain and yet it costs thousands of dollars more.

For the record, NICE doesn’t cover Zaltrap, either.

So kudos to Memorial Sloan Kettering for not only recognizing the elephant in the room, but embracing it.

UPDATE: Thanks to a keen blog follower who just alerted me to the fact that Sanofi-Aventis lowered the price of Zaltrap on Thursday in response to the Sloan Kettering move.  The New York Times wrote that the move “could be a sign of resistance to the unfettered increase in the prices of cancer drugs, some of which cost more than $100,000 a year and increase survival by a few months at best.”

You see, it does pay to draw attention to the elephant!


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