Hacker News Reader

When government pays for your healthcare some civil servants who look at you as merely statistics make that call to keep you alive or to let you die. In that sense the money spent is actually controlled.

In USA there is this weird concept that "all lives matter more than anything else" and hence doctors spend millions.

Well it's a concept, but it's applied very hypocritically. It seems mostly about social status. "All lives matter more than anything else but some lives don't matter very much at all" would be more accurate. Some people get millions of dollars in treatment (they're wealthy or have employment with a company with good insurance) while others die slowly for lack of a few bucks for a prescription (they already lost their jobs due to previous illness, mental illness or addiction, or just got unlucky with timing).

Politicians in certain states and in the federal government are doing their best to make sure people without jobs can't get help with affording treatment as well. Frankly to claim that we in the US care more about lives than those in other developed nations with rational disbursement of healthcare funding is just wrong.

Sorry if you weren't implying that, but I think you were.

The person who has lost job or does not have a good job is not likely going to have much of a life either even if he is cured. If he has hope of having a good life he might as well borrow some reasonable money.

This might sound evil but what is really evil here is the US government and FDA that has put regulations which essentially say you will either get best possible treatment or none.

It is not clear to me why the prescription system is so ridiculously regulated. Not clear to me why people having opioids is such a big deal and why we can't have more of health workers giving minor treatment instead of just doctors.

In country like India there will be lot of quacks who are not real doctors and yet serve in villages where no real doctor would work.

Except for those of the uninsured who are left to die.

That happens in the USA too, except the bureaucrats are in large insurance corporations vs. large government organizations.

Yes and I find it surprising that people demanding socialised medicine in USA somehow think giving complete monopoly to government over medicine will not screw things up.

They look at other countries and see how much better it is? There is a reason why it's in demand ;)

And the above case precisely shows why they might be terribly wrong.

>>However, if it cures a person and the person lives a good quality life for 20 years, then the cost per quality adjusted life year is around $50,000.

However, usually cancer strikes older people. http://www.cancerresearchuk.org/health-professional/cancer-s... A computer doing a blind cost benefit might say to let them die, as they will retire and enjoy social security and so on.

By your logic any procedure that prevents death is cost adjusted by how many years the patient lives. It 'proves too much'. If I'm 30 and I suffer a knife wound then you could charge any amount to prevent my death, justifying by averaging over 40 years. All kinds of medical intervention may be necessary to prevent death, but that doesn't mean they shouldn't be affordable.

I think the point is to set an upper bound on how much a government ought to be willing to pay for a given procedure, and to compute that upper bound by counting QALYs and multiplying by their official dollar value.

For example:

Value of stitching knife wound: (40 QALYs) * (30,000 GBP/QALY) = 1.2M GBP

Cost of stitching knife wound: (let's say) 1000 GBP

Decision process:

Is the cost less than the value? 1000 < 1.2M, so yes. Therefore, pay for the procedure.

Whereas:

Value of expensive cancer procedure on 70-year-old: Let's say 5 QALYs just to make up something, taking into account expected lifespan and QOL and chance of remission, etc, times the same 30k GBP, = 150k GBP.

Cost of procedure: 1M GBP

Decision process:

Is the cost less than the value? 1M > 150k, so no. Therefore, don't pay for the procedure.

I, and a lot of other people, don’t like this thought process. We are quite bad at estimating how much someone has left to live. We are worse at estimating the quality of the life someone will experience. And then that someone may be single, with no family, or have 3 kids still in elementary school. Are you going to consider the quality of life of their dependents. What if that person is about to solve the nuclear fusion, or the Riemann hypothesis, would you pay 1M to keep them alive one more year? Would you let them die after their work is done?

I think it's reasonable to not be totally comfortable with that. But can you think of a better system?

To address the important scientist point you made, I could see it being in the interest of society to give some people extra special care (e.g. the US president gets top care), although mostly it's hard to value what should qualify someone, as you say. I think in some heartstrings cases we see GoFundMe's and such filling the gap; perhaps that's the proper role for charity in the system?

I believe these assessments are made on a general rather than an individual basis. It's not a question of whether treatment should be approved for an individual patient ("death panels") but whether a treatment is sufficiently effective for its cost to be made available.

I was trying to correct what seemed to me to be a miscommunication (I thought my parent post misunderstood something about what GP comment was saying). I wasn't trying to endorse or condemn any particular system for evaluating procedures, in my earlier comment; just pointing out that the system wasn't flawed on its own terms in such an obvious way.

Can anyone from a socialized medicine country explain how this particular treatment would be dispensed in their country? I'm an American and wondering, for example, would government of the Netherlands truly front this $1mm per treatment cost for every cancer patient?

I'm not from such a country, but I do listen to The Weeds (a policy podcast) and they have discussed how it works. Roughly speaking, there are committees that look at the efficacy of new treatments and their costs, and they decide what they will pay for a given treatment. Then the drug maker decides if they will sell it at that price. There are cases where the government will not pay the drug maker's reserve price. For example, there was a period of time where Kadcyla was not available in the UK. Then, after a while, the drug maker decided to reduce their reserve price, and now it seems the Britons can get the drug.

This national pricing leverage is a big part of why drugs are cheaper in countries with national price setting. Socialized medicine is actually less of a factor in this space. What matters is whether a single entity has the ability to set prices for the entire market (or a sufficiently large slice of it).

https://pharmaphorum.com/news/kadcyla-set-regular-nhs-fundin...

This just makes so much more sense than the US's broken system. Is there a corollary to what you describe such that the governments could periodically publish a list of priorities, thus incentivizing private research into a particular categories (certain types of cancers, alzheimers, etc)?

I'm not from an EU country, but I'm familiar with it.

A lot of European countries do a health technology assessment to determine the cost effectiveness. If it's not cost effective, they don't pay for it.

Glybera was approved in the EU and Germany pays for it and it costs $1M.[1] Of course, very very few patients have or will be treated with it.

[1]http://blogs.nature.com/tradesecrets/2015/03/03/1-million-pr...