[Congressional Record Volume 155, Number 101 (Wednesday, July 8, 2009)]
[Senate]
[Pages S7254-S7255]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]




                          BRITISH HEALTH CARE

  Mr. KYL. Mr. President, a July 7, 2009, Wall Street Journal editorial 
``Of NICE and Men'' describes the denial and delay of health care in 
Britain as a result of decisions by the British government's health 
care cost-containment board, the National Institute for Health and 
Clinical Excellence, NICE.
  The article quotes the Guardian, which in 1998 reported, ``Health 
ministers are setting up [NICE], designed to ensure that every 
treatment, operation, or medicine used is the proven best. It will root 
out under-performing doctors and useless treatments, spreading best 
practices everywhere.''
  Yet NICE routinely denies patients the very treatments and 
medications they need.
  For example, according to the editorial, ``NICE ruled against the use 
of two drugs, Lapatinib and Sutent, that prolong the life of those with 
certain forms of breast and stomach cancer.''
  Explaining the ruling against the use of a drug that would help 
terminally ill kidney-cancer patients, Peter Littlejohns, NICE's 
clinical public health director, said there is ``a limited pot of 
money.''
  The editorial provides numerous other examples of drugs and 
treatments that are either denied or restricted in order to reduce 
costs.
  And it explains how NICE has even assigned a mathematical formula for 
determining the maximum amount the government will spend to extend a 
life for 6 months.
  President Obama has praised countries that spend less than the U.S. 
on health care, while saying we can spend less here too, even while 
adding tens of millions to a government-run health care program and 
improving the quality of care.
  This editorial clearly and concisely outlines why this cannot be 
achieved and why, if President Obama's health care plan passes, the 
administration's new Council for Comparative Effectiveness Research 
could eventually gain the same authority to deny or delay treatments 
and care as Britain's NICE.
  I ask unanimous consent that this article be printed in the Record, 
and urge my colleagues to consider the facts and arguments contained in 
this editorial.
  There being no objection, the material was ordered to be printed in 
the Record, as follows:

              [From the Wall Street Journal, July 7, 2009]

                            Of NICE and Men

       Speaking to the American Medical Association last month, 
     President Obama waxed enthusiastic about countries that 
     ``spend less'' than the U.S. on health care. He's right that 
     many countries do, but what he doesn't want to explain is how 
     they ration care to do it.
       Take the United Kingdom, which is often praised for 
     spending as little as half as much per capita on health care 
     as the U.S. Credit for this cost containment goes in large 
     part to the National Institute for Health and Clinical 
     Excellence, or NICE. Americans should understand how NICE 
     works because under ObamaCare it will eventually be coming to 
     a hospital near you.
       * * *
       The British officials who established NICE in the late 
     1990s pitched it as a body that would ensure that the 
     government-run National Health System used ``best practices'' 
     in medicine. As the Guardian reported in 1998: ``Health 
     ministers are setting up [NICE], designed to ensure that 
     every treatment, operation, or medicine used is the proven 
     best. It will root out under-performing doctors and useless 
     treatments, spreading best practices everywhere.''
       What NICE has become in practice is a rationing board. As 
     health costs have exploded in Britain as in most developed 
     countries, NICE has become the heavy that reduces spending by 
     limiting the treatments that 61 million citizens are allowed 
     to receive through the NHS. For example:
       In March, NICE ruled against the use of two drugs, 
     Lapatinib and Sutent, that prolong the life of those with 
     certain forms of breast and stomach cancer. This followed on 
     a 2008 ruling against drugs--including Sutent, which costs 
     about $50,000--that would help terminally ill kidney-cancer 
     patients. After last year's ruling, Peter Littlejohns, NICE's 
     clinical and public health director, noted that ``there is a 
     limited pot of money,'' that the drugs were of ``marginal 
     benefit at quite often an extreme cost,'' and the money might 
     be better spent elsewhere.
       In 2007, the board restricted access to two drugs for 
     macular degeneration, a cause of blindness. The drug Macugen 
     was blocked outright. The other, Lucentis, was limited to a 
     particular category of individuals with the disease, 
     restricting it to about one in five sufferers. Even then, the 
     drug was only approved for use in one eye, meaning those 
     lucky enough to get it would still go blind in the other. As 
     Andrew Dillon, the chief executive of NICE, explained at the 
     time: ``When treatments are very expensive, we have to use 
     them where they give the most benefit to patients.''
       NICE has limited the use of Alzheimer's drugs, including 
     Aricept, for patients in the early stages of the disease. 
     Doctors in the U.K. argued vociferously that the most 
     effective way to slow the progress of the disease is to give 
     drugs at the first sign of dementia. NICE ruled the drugs 
     were not ``cost effective'' in early stages.
       Other NICE rulings include the rejection of Kineret, a drug 
     for rheumatoid arthritis; Avonex, which reduces the relapse 
     rate in patients with multiple sclerosis; and lenalidomide, 
     which fights multiple myeloma. Private U.S. insurers 
     often cover all, or at least portions, of the cost of many 
     of these NICE-denied drugs.
       NICE has also produced guidance that restrains certain 
     surgical operations and treatments. NICE has restrictions on 
     fertility treatments, as well as on procedures for back pain, 
     including surgeries and steroid injections. The U.K. has 
     recently been absorbed by the cases of several young women 
     who developed cervical cancer after being denied pap smears 
     by a related health authority, the Cervical Screening 
     Programme, which in order to reduce government healthcare 
     spending has refused the screens to women under age 25.
       We could go on. NICE is the target of frequent protests and 
     lawsuits, and at times under political pressure has reversed 
     or watered-down its rulings. But it has by now established 
     the principle that the only way to control health-care costs 
     is for this panel of medical high priests to dictate limits 
     on certain kinds of care to certain classes of patients.
       The NICE board even has a mathematical formula for doing 
     so, based on a ``quality adjusted life year.'' While the 
     guidelines are complex, NICE currently holds that, except in 
     unusual cases, Britain cannot afford to spend more than about 
     $22,000 to extend a life by six months. Why $22,000? It seems 
     to be arbitrary, calculated mainly based on how much the 
     government wants to spend on health care. That figure has 
     remained fairly constant since NICE was established and 
     doesn't adjust for either overall or medical inflation.

[[Page S7255]]

       Proponents argue that such cost-benefit analysis has to 
     figure into health-care decisions, and that any medical 
     system rations care in some way. And it is true that U.S. 
     private insurers also deny reimbursement for some kinds of 
     care. The core issue is whether those decisions are going to 
     be dictated by the brute force of politics (NICE) or by 
     prices (a private insurance system).
       The last six months of life are a particularly difficult 
     moral issue because that is when most health-care spending 
     occurs. But who would you rather have making decisions about 
     whether a treatment is worth the price--the combination of 
     you, your doctor and a private insurer, or a government board 
     that cuts everyone off at $22,000?
       One virtue of a private system is that competition allows 
     choice and experimentation. To take an example from one of 
     our recent editorials, Medicare today refuses to reimburse 
     for the new, less invasive preventive treatment known as a 
     virtual colonoscopy, but such private insurers as Cigna and 
     United Healthcare do. As clinical evidence accumulates on the 
     virtual colonoscopy, doctors and insurers will be able to 
     adjust their practices accordingly. NICE merely issues 
     orders, and patients have little recourse.
       This has medical consequences. The Concord study published 
     in 2008 showed that cancer survival rates in Britain are 
     among the worst in Europe. Five-year survival rates among 
     U.S. cancer patients are also significantly higher than in 
     Europe: 84% vs. 73% for breast cancer, 92% vs. 57% for 
     prostate cancer. While there is more than one reason for this 
     difference, surely one is medical innovation and the greater 
     U.S. willingness to reimburse for it.
       * * *
       The NICE precedent also undercuts the Obama 
     Administration's argument that vast health savings can be 
     gleaned simply by automating health records or squeezing out 
     ``waste.'' Britain has tried all of that but ultimately has 
     concluded that it can only rein in costs by limiting care. 
     The logic of a health-care system dominated by government is 
     that it always ends up with some version of a NICE board that 
     makes these life-or-death treatment decisions. The 
     Administration's new Council for Comparative Effectiveness 
     Research currently lacks the authority of NICE. But over 
     time, if the Obama plan passes and taxpayer costs inevitably 
     soar, it could quickly gain it.
       Mr. Obama and Democrats claim they can expand subsidies for 
     tens of millions of Americans, while saving money and 
     improving the quality of care. It can't possibly be done. The 
     inevitable result of their plan will be some version of a 
     NICE board that will tell millions of Americans that they are 
     too young, or too old, or too sick to be worth paying to care 
     for.

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