Aromin, Paula Benilda C.

MPM-HG Cohort C 2019 HTAREG

Essay on Health Technology Assessment

I. Introduction

The film “Price of Life” chronicled the decision-making process of NICE (the National
Institute for Health and Clinical Excellence) about the cancer drug Revlimid with
Lenalidomide and being made accessible to the people dying of myeloma. It was a process
of choosing between the costly cancer drugs for one cluster of patients and extending the
life of these patients. The award-winning documentary-maker Adam Wishart’s insightful and
balanced movie went after those who must make a decision on whether to approve the
drug and those who will be affected by the resolution. They were cancer patients including
Julia Gatt and Eric Rutherford, whose lives depended on the resolution; Sol Barer, head of
the American drug company that found Revlimid and profits from it; Professor David
Barnett, the chairman of the NICE appraisals committee, a cardio-vascular consultant and
charged with assessing Revlimid’s cost-effectiveness; and NHS manager Sophia Christie,
who has to cope with the bottom-line financial repercussions or implications of the
committee's decision.

II. How much is a life worth, and how much should society pay?

The National Health Service (NHS) has the agency, National Institute for Health and
Clinical Excellence (NICE), tasked with endorsing and advancing clinical excellence in NHS
service providers in England and Wales, by improving management, regulations, and
recommendations on the effectiveness of treatments and medical procedures. The
recommendations are issued in the form of "technology appraisals." These are based on a
review of the evidence of clinical and cost-effectiveness for a particular technology and give
recommendations if and how and under what contexts the technology should be utilized in
the NHS. NICE evaluated most of the technologies to be pharmaceutical in nature, but it
has also taken into account surgical procedures, medical devices, and screening
technologies. 1

In the documentary, NICE was arguing about the cost-effectiveness of Revlimid

given the agency’s limit to allocate spending per Quality-Adjusted Life Year (QALY). QALY
is a measure of the value and benefit of health outcomes. It is used to guide/inform health
policy and is accepted as an outcome measure in health economics. 2 Since health is a
function of the length of life (mortality) and quality of life (morbidity), the QALY was
formulated as an attempt to bring together the value of those elements into a single index
number. Thus, this parameter is useful in comparing the cost-effectiveness of any treatment
as in the case of Revlimid in the movie. Cost-effectiveness analysis is a method to
scrutinize both the costs and health outcomes of one or more interventions. It compares an
1
https://www.politics.co.uk/reference/national-institute-for-health-and-clinical-excellence/ Accessed
Feb. 12, 2020
2
Briggs AH, Goldstein DA, Kirwin E, Meacock R, Pandya A, Vanness DJ et al. Estimating (quality‐
adjusted) life‐year losses associated with deaths: With application to COVID‐19. Health Economics.
2020; online version ahead of print.
intervention to another intervention (or the status quo) by estimating how much it costs to
gain a unit of a health outcome like a life-year gained or death prevented. 3

In the movie, the first committee meeting of NICE on the argument of accepting and
recommending Revlimid for cancer-stricken patients opted to reject it based on its cost-
effectiveness. The committee chair understood the parochial concerns of the patients as a
major concern. However, it was noted that they are not willing to pay for such expense but
would rather transfer the cost to the government as they have paid for it during the
productive or working life. The cost per QALY is £30,000. Revlimid comes in at just under
£50,000 per patient. The NICE committee decided that the cost was too much compared to
the benefits that it offered – the best evidence was that it delayed the disease from
progressing for six months. The United Kingdom has single-payer health care that covers
all residents.4 The National Health Service operates hospitals and compensates doctors as
employees. The government shoulders 80% of costs owing to income and payroll taxes.
The rest is paid from copayments and people shelling out-of-pocket for NHS services. It
pays for all medical care, including some dental and eye care, hospice care, and some
long-term care. Having these in mind, from Prof. Barnett’s and Sophia Christie’s points of
view, it was right for them to consider the trade-offs in deciding on the matter in favor of
value for money and, at the same time, governing an effective healthcare system that is on
a budget. NICE has to stand outside the emotions with the bigger picture in mind, with
everyone in view and not just a group of people already with end-of-life morbidities. This is
somehow an application to the utilitarian philosophy that aims for the benefit of society in
general. The accessibility of the drug may be allowed but only a few will benefit but would
gather much of the limited resources that could be devoted for the others with a greater
population. Unfortunately, the decision was reversed out of deadlock after 3 months this
time primarily in response to patient pressure and from the politicians. This time I do not
agree with the NICE committee’s decision to go in favor of the Revlimid despite the
pharmaceutical Celgene’s counteroffer to lower their price (still above the threshold) and
render the succeeding drugs free if the patient survives beyond two years. My reason
behind this is that the price of Celgene is not based on the true manufacturing cost of the
product but on the PERCEIVED value (or how much people they think people will pay for it)
and has no competitor in the market. Secondly, I would have agreed on the decision if the
political powers provided additional appropriated funds for NICE to work on for high-cost
medicines as argued by Ms. Sophia Christie because NICE will have to re-align their funds
from others that could have benefited from the funds.

III. “Any extension of life is paramount.”

Being a military nurse, especially in a battle zone, our main mission is to save the life
and limbs of wounded soldiers. Anything that would extend someone’s life is supreme in
consideration because the patient is in a life or death situation. There is the immediate need
to preserve life regardless of the cost. However, given the arguments in the movie, as Prof.
Barnett claimed, “an extension of life is already in the end-of-life” is relative. Universal
3
https://www.cdc.gov/policy/polaris/economics/cost-effectiveness.html. Accessed Feb 11, 2020.
4
The Commonwealth Fund. "The English Health Care System ," Accessed Feb. 11, 2020.

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Health Care or coverage (UHC) provides that “ALL people have access to the health
services they need, when and where they need them, without financial hardship. It includes
the full range of essential health services, from health promotion to prevention, treatment,
rehabilitation, and palliative care.”5 I highlighted palliative care because this is specialized
medical care that concentrates on offering patients relief from pain and other symptoms of a
serious illness, no matter the diagnosis or stage of disease (including end-of-life
morbidities). Palliative care teams render an improvement in the quality of life for both
patients and their families. As shown in the movie through Ms. Christie, NICE offers hospital
or home care for comfort and peace for people who are in their end-of-life stage. As Adam
Wishart said, how a person dies are as important as when the person dies if WHEN would
only mean a few more painful months. Putting it simply, one has the option not to prolong
the agony if one is dying anyway. Thus, in the absence of the life-extending drug because
of its cost, NICE offers another option to provide less costly health care and because it
saves money compared to Revlimid, that money can be used for other means for the good
of the many.

IV. Acceptable approach to provide access to new expensive treatments especially in a

low- to a middle-income country like the Philippines

UHC does not mean free coverage for all possible health interventions, a
misconception, regardless of the cost, as no country can provide all services free of charge
on a sustainable basis. In the case of the less developed countries like the Philippines,
many services could not be provided for free. It would make sense therefore to apply the
QALY measurement in assessing new and expensive interventions for their value for
money and using the utilitarian philosophy or for the good of the many in deciding whether
to provide access to such expensive interventions. If many people would benefit from such
intervention, then the cost or price, by the principle of economies of scale, would be
substantially lowered.

5
https://www.who.int/health-topics/universal-health-coverage#tab=tab_1 Accessed Feb. 12, 2020.

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