Lim­it­ing health care by the num­bers

How ‘value frame­works’ threaten pa­tient ac­cess

The Washington Times Daily - - COMMENTARY - By Jonathan Wil­cox Jonathan Wil­cox is the co-founder and pol­icy di­rec­tor of Pa­tients Ris­ing.

When Sen. John McCain re­turned to Wash­ing­ton re­cently and stepped onto the Se­nate floor fol­low­ing a di­ag­no­sis of brain can­cer, the af­fec­tion and ad­mi­ra­tion from both sides of the aisle was clear. Ex­pect this bi­par­ti­san goodwill to en­dure even fol­low­ing his con­tro­ver­sial vote killing the “skinny re­peal” of Oba­macare.

Now back in Ari­zona get­ting treat­ment, Mr. McCain is demon­strat­ing what it means to live one’s life as a pa­tient to the fullest. Well-wish­ers are also en­cour­ag­ing him to fight his disease us­ing any treat­ment op­tion that’s right for him, in­clud­ing surgery, ra­di­a­tion, chemo­ther­apy and im­munother­apy. The mes­sage is clear: what­ever he needs, he should re­ceive.

It’s unimag­in­able that any of the sen­a­tor’s col­leagues would sug­gest that since Mr. McCain soon turns 81, sur­vived a pre­vi­ous can­cer, and has sev­eral ad­di­tional health chal­lenges, maybe it’s best to limit how much the sys­tem in­vests in him be­cause he prob­a­bly doesn’t have that long to live.

Sound harsh? It sure does — but mil­lions of other pa­tients are fac­ing that judg­ment ev­ery day. A na­tion­wide move­ment is on­go­ing and ac­cel­er­at­ing to ap­ply a rigid, for­mu­laic process to de­ter­mine if pa­tients are too costly to treat and their lives too ex­pen­sive to save.

This is the on­go­ing fight for pa­tient ac­cess to ad­vanced medicines and ther­a­pies for those fac­ing a chronic disease or se­ri­ous ill­ness, and it’s the in­tel­lec­tual fault line run­ning down the mid­dle of any se­ri­ous de­bate about the fu­ture of health care in Amer­ica.

At a time of break­through ad­vances in pre­ci­sion and per­son­al­ized medicine, none of us seems shocked any­more when med­i­cal mir­a­cles oc­cur.

Just 20 years ago, a 90-year-old man with can­cer in his liver and brain faced a grim death sen­tence. Jimmy Carter got that di­ag­no­sis in 2015, but he re­ceived cut­tingedge im­munother­apy treat­ments and walked out of his hospi­tal after six months of treat­ment. That was 18 months ago. He’s still walk­ing.

Mr. Carter and Mr. McCain are ob­vi­ously ex­cep­tional pa­tients, but they shouldn’t be ex­cep­tions to a sys­tem that would serve them first and best, and the rest of us last and half-heart­edly.

How is this hap­pen­ing? Some­thing new is tak­ing hold in health care: value frame­works. These are com­pli­cated math­e­mat­i­cal for­mu­las on pa­tients, rigid price con­trols on ad­vanced med­i­ca­tions and, ul­ti­mately, lim­its on the kind of treat­ment ac­cess John McCain is re­ceiv­ing right now.

This is all in the name of “sys­tem man­age­ment,” and it is be­ing promi­nently ad­vanced by the most in­flu­en­tial think tank few have heard about: the Bos­ton-based In­sti­tute for Clin­i­cal and Eco­nomic Re­view (ICER).

Backed by mil­lions of dol­lars from one foun­da­tion, ICER has aligned with the in­sur­ance in­dus­try and phar­macy ben­e­fit man­agers (PBMs) to im­pose value frame­works and cut costs by re­strict­ing treat­ment — some say reck­lessly. For ex­am­ple, Dr. Robert Goldberg of the Cen­ter for Medicine in the Pub­lic In­ter­est es­ti­mates that not only will ICER’s value frame­works fail to en­hance treat­ment op­tions for pa­tients suf­fer­ing from the blood can­cer mul­ti­ple myeloma, they will cut off and kill 44,000 of them.

ICER has also turned its harsh light on treat­ments for lung can­cer, car­dio disease, os­teo­poro­sis, arthri­tis, pso­ri­a­sis, mi­graines and sev­eral other se­ri­ous con­di­tions. Like a three-card monte street hus­tle, no mat­ter how the data gets shuf­fled, the re­sult is al­ways the same: wide­spread pa­tient treat­ment is too ex­pen­sive and it’s time to cut peo­ple off.

Just last year, ICER en­joyed easy ac­cess to the Obama ad­min­is­tra­tion, in­clud­ing its Health and Hu­man Ser­vices Agency. And it bet big that Pres­i­dent Hil­lary Clin­ton would have fused ICER’s frame­works and fed­eral pol­icy.

That ob­vi­ously didn’t hap­pen, but ICER is still bur­row­ing into Wash­ing­ton, boast­ing that the Vet­er­ans Ad­min­is­tra­tion will ap­ply its es­ti­mates to de­cid­ing what medicines vet­er­ans will re­ceive. Dr. Goldberg adds: “This would only mean that un­like Sen­a­tor McCain, thou­sands of vet­er­ans will be de­nied ac­cess to treat­ments that could save their lives.” That’s what makes this an ideal time to set straight once and for all what should be the de­fault set­ting of the health care sys­tem: get­ting the right pa­tient the right treat­ment at the right time.

It’s a move­ment in search of a nat­u­ral leader. Some­one will­ing to take on en­trenched in­ter­ests, call out cor­rupt poli­cies and tell the truth about what is hap­pen­ing to pow­er­less pa­tients. Sounds like a mis­sion for a mav­er­ick to me.


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