OP-ED

Health Panels are a NICE Way of Improving Care and Controlling Costs

By ADRIAN BAKER

One of the proposals for health care reform is to have a panel of medical experts oversee Medicare, in order to improve quality and reduce cost. Butfalse accusations permeating the debate have scared people into thinking that would mean a government bureaucrat deciding what treatments you should or shouldn’t have, and would ultimately deny your grandma her vital drugs. Like any debate involving the future, fear of the unknown is going to be used by those who want to maintain the status quo for their own self interest. But health panels are not unknown. They have been used in Britain for ten years, and have proven to work.

Health panels are a simple enough idea: experts look at the evidence out there and make sure it’s the best that is available. They then make recommendations based on analysing hundreds of studies and consulting numerous stakeholders. The recommendations suggest the best form of treatment and care for a particular condition, or advise on areas your doctor may be unsure about.

The recommendations aren’t mandatory, the government isn’t involved, and there is no tying of hands. The decision to follow these recommendations will always be with your doctor, because they know you best. All that happens is that your doctor can make a better, more informed decision and will no longer have to choose between spending time treating you or spending time reading up on the latest evidence.

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23 replies »

  1. While it is nice in theory to leave medical decisions to the patient, their doctor and family, that doesn’t work too well when they’re playing with house money.
    I think that the oversight of medical experts is needed to help wade through the emotion and look critically at whether spending of quasi-public dollars on a particular treatment is justified given the medical issues including patient health status.

  2. “However, one word about QALYS and health panels. As should be the case, health panels such as NICE are completely independent from the government, use fully transparent methodologies and include all stakeholders in the consultation period. Rightly so, it is completely detached from the government, so using QALYS for political decisions is not possible. ”
    With all due respect Adrian this statement assumes there is agreement that it is even possible to discern QALY’s accurately much less how all life is diminished when mathematical constructs determine its length. Such agreement does not exist. In fact there is great disagreement as the whole abortion issue illustrates.

  3. “”Under the guidelines the decision to diagnose that a patient is close to death is made by the entire medical team treating them, including a senior doctor”. The guidelines clearly state that the senior doctor and the entire team should make the decision.”
    This is true but that senior doctor and entire medical team is also an employee of NHS are they not? The same entity setting the guidelines, manages the budget and pays the doctor who makes the determination. I don’t see any independence at any stage.
    Let’s look at home, look how Clinton sacked the travel office, Bush canned the AGs, and the worst of the three what Obama has done to supposed independent Inspector Genrals who got in his way. No panel appointed by politicians or those under the control of politicians and subject to federal budgets will ever be independent.
    On paper these ideas all sound great, things never happen like they are drawn on paper and ignoring those consiquences is what makes these huge messes we are in now. Dems never meant Medicare to cost 100 billion instead of 9 billion, Kennedy never meant HMOs to turn out like they did, and COBRA wasn’t meant to be the litgasious nightmare it was…but they all did.

  4. I agree with ravi that the debate is not driven by logic but by self interests. Case in point with cancer medicine. Based on clinical trials results showing no difference between single agent platinums versus platinum/Taxol (GOG Trial # 132, ICON3), NICE determined that platinum/Taxol should no longer be considered as “standard therapy” and that a range of therapies are equally acceptable (doctors could think for themselves). In the USA, where the administration of platinum/Taxol has been much more profitable to the treating oncologist than single agent platinum, there has been the dogged insistance that platinum/Taxol remains “standard,” despite clear lack of support for this position, based on the entirety of the clinical trials literature.

  5. I don’t understand how this differs from what we have to day, which is insurance companies making the decision. I know a family whose child has a rare pediatric cancer called neuroblastoma. All high risk neuroblastoma cases are treated on clinical trials designed by COG. That is the standard of care – in fact, there are no treatments outside of clinical trials. This family was randomized to a tandem transplant on the current COG Phase III trial. But their insurance company is refusing to pay, saying that this is experimental. I am not seeing how this is any different from what happens in the U.K.

  6. Sounds fine in theory, but you should really have mentioned QALYs and how they are used in the UK (or interestingly how they may have been used in a case such as Sen. Kennedy’s condition and age.
    The American people do not understand that to have any hope of managing health care costs, there has to be a way to, well, manage those costs. Call it rationing or call it managed care … oh wait we all ready tried that and screwed it up.
    http://www.quinnscommentary.com

  7. Many thanks for all your comments. Just to pick up on a couple of points:
    With regards to the letter in the Daily Telegraph (it should be noted, however, that the DT is not impartial, and neither are the people they quote), I think this statement should be emphasised:
    “Under the guidelines the decision to diagnose that a patient is close to death is made by the entire medical team treating them, including a senior doctor”. The guidelines clearly state that the senior doctor and the entire team should make the decision.
    Robert, you make some good points. You’re right in saying that guidelines eventually become a de facto standard of care. Whilst a doctor has every right and freedom to ignore the guidelines if they feel the patient is an unusual case, the guidelines are there partly to ensure that doctors base their decisions on the latest and best (emphasis on best) evidence. Basing decisions on experience, whilst very useful in a number of instances, can lead to inappropriate treatment and care in other cases (and of course medical history is full of these lessons). However, one word about QALYS and health panels. As should be the case, health panels such as NICE are completely independent from the government, use fully transparent methodologies and include all stakeholders in the consultation period. Rightly so, it is completely detached from the government, so using QALYS for political decisions is not possible.
    Stephen, it is indeed possible for these panels to execute their mission. They have done so for the last ten years. Please refer to their methodology: http://www.nice.org.uk/aboutnice/howwework/developingniceclinicalguidelines/developing_nice_clinical_guidelines.jsp
    In fact, many American medical societies produce guidelines in a similar way. Whilst you’re right in saying there is an enormous amount of information to go through, their methodology makes this manageable by reducing the amount of papers through advanced search criteria and then appraising the papers using full time, expert methodologists. With regards to NLP: this is actually quite a contentious issue. The reason is because doctors are not trained methodologists. So when they read a paper, they have to rely on experience and judgment on whether they follow it. That is OK, but definitely not the best scenario that can be had. Whilst it is required and wanted that doctors keep up with the latest evidence, some bad studies (see the case between the widely condemned study ‘linking’ MMR to autism) can get through the cracks. Doctors are not trained to spot whether a study includes methodological bias, is poorly constructed or has any other problems (the study design could be inappropriate, the confidence interval too weak to make a good conclusion, etc). So putting this information in front of doctors, whilst useful, should not be used as a substitute for expert health panels who appraise the strength of the paper.
    Again, many thanks for comments and hope some further informed debate can be had

  8. It’s refreshing to see Republicans so concerned for the helpless and disadvantaged (political crocodile tears?). Too bad they can’t entend that heart felt concern to the millions who suffer premature death from not being able to pay for medical care.

  9. I firmly believe we need a public option that will not eliminate people when they get sick or raise deductibles so people can’t afford to use their health insurance when they need it. This is more than a fight to include the uninsured. This is trying to preserve an option for the middlle class at all.
    The private health insurance continue to raise rates while the CEO’s and top officers of these private companies pocket millions of dollars. How can a company
    that pays its executives millions of dollars in bonuses be call non-profit any way.

  10. “In 2007-08 16.5 per cent of deaths in Britain came about after continuous deep sedation, according to researchers at the Barts and the London School of Medicine and Dentistry, twice as many as in Belgium and the Netherlands.”
    Who would have thought republican obstructionists had such a covert network that included palliative care providers in the UK? Imagine the planning that took for Gingrich & Palin.

  11. Adrian,
    Is this the type of panel you are suggesting?
    http://www.telegraph.co.uk/health/healthnews/6127514/Sentenced-to-death-on-the-NHS.html
    “In a letter to The Daily Telegraph, a group of experts who care for the terminally ill claim that some patients are being wrongly judged as close to death.
    Under NHS guidance introduced across England to help doctors and medical staff deal with dying patients, they can then have fluid and drugs withdrawn and many are put on continuous sedation until they pass away.
    But this approach can also mask the signs that their condition is improving, the experts warn.
    As a result the scheme is causing a “national crisis” in patient care, the letter states. It has been signed palliative care experts including Professor Peter Millard, Emeritus Professor of Geriatrics, University of London, Dr Peter Hargreaves, a consultant in Palliative Medicine at St Luke’s cancer centre in Guildford, and four others.”
    “The scheme, called the Liverpool Care Pathway (LCP), was designed to reduce patient suffering in their final hours.
    Developed by Marie Curie, the cancer charity, in a Liverpool hospice it was initially developed for cancer patients but now includes other life threatening conditions.
    It was recommended as a model by the National Institute for Health and Clinical Excellence (Nice), the Government’s health scrutiny body, in 2004.
    It has been gradually adopted nationwide and more than 300 hospitals, 130 hospices and 560 care homes in England currently use the system.”

  12. I’ll take my chances on working with a legislator that can be voted out of office rather than dealing with a panel full of biased and self serving agendas, thank you.

  13. Detach the billed dollars from care and see how fast we won’t need “Qualy Metrics” to control health dollars.

  14. The earlier comments above suggest that the US health care system is at a higher plane than the systems in other parts of the world. Please take a closer look at the data on where one is more likely to receive evidence-based care and where mortality and morbidity statistics suggest that citizens are healthier. It’s certainly not the US, which ranks around many Third World countries. We’re much more likely to improve if we look at what has worked elsewhere and borrow from these working models.

  15. I think what is missing in those communications is that these would be at an aggregate level to create guidlines. May be that is what we should call them – an effective medicine utilization guidance panel or even something cuter.
    The debate today is not driven by logic but by self interests. And then it become very difficult to create a solution.
    It may be OK to ram a solution through like Bush did…because people who are the distractions will not change their mind – it not right or wrong, it is an idealogue for them.
    rgds
    ravi
    blogs.biproinc.com/healthcare
    http://www.biproinc.com

  16. Contrary to Adrian Baker’s suggestion that using health care review panels will improve quality and lower cost of health care, it is no longer possible for such panels to effectively execute their mission. Today, the volume of information required for review far exceeds the grasp of the collective mind of any expert panel.
    Newer technology using NLP (Natural language Porcessing) are able to scan digitized data, strucred or non structured, and put useful accurate and current information in front of doctors and patients at the time medical care decisions are being made.
    What this op ed appropriate highlights, however, is the inmportance of putting trusted accurate information in the hands of clinicians and patients at the right time.
    Health Panels represent an innacurate and too expensive way to improve medical care decisions.

  17. Thanks for putting a NICE face on it. I just talked to a colleague from UK who suffered an audit from NICE panel. Apparently in practice, NICE is anything but. According to him, the so-called guidelines are NOT suggestions. If you exercise clinical judgement, your care is “substandard.” So please, these Panels are less about healthcare quality than they are about Money.

  18. There is nothing ‘nice’ about a health care panel! Answers to the following questions should scare any rational person not in the tank for feel good slogans: 1)What would such a panel discuss?, 2)Would they develop one size fits all medical guidelines for who gets health care or would they consider the differing needs of each American citizen? 3)Would they restrict treatments, of any kind, recommended by the primary care physician? How would they handle exigencies that arise regularly with patients that are physiologically different and react to different treatments much differently? I could go on, but you get the idea!
    Grow up and use less emotion in your thinking!!

  19. Although health panels are a simple enough idea as noted by Adrian Baker, their implication and operational impact is far from simple. Although Adrian notes that what they do are “recommendations” and are not mandatory, they will soon be considered the standard of care (not necessarily bad but requires a complete change in how health care today is delivered and also a major change in American expectations and culture). Secondly, they can control the benefits (what will be paid for) and thus indirectly dictate “their view” of the truth. Not necessarily bad, but again, requiring major change in expectations of Americans how they receive health care benefits. It is rationing, but any system has to ration to stay within a “sustainable budget.” However, casual remarks about Qaly (Quality of life adjusted for years)is onerous considering the leadership surrounding the President and their well published views on making societal decisions for those who have Value to Society. So far no plan in American uses Qaly metrics for benefit determination–they just remove it for all agnostic to age and societal value. It is a slippery slope and if we go this (Qaly)direction, the panel must be apolitical, impeachable and fully transparent. If we jump onto this slippery slope (slime), our elders do need to be concerned and thus mitigate that concern by having the correct controls in place or replace the panel.

  20. What a bunch of huff n’ puff. Anyone with money in GB comes to the USA or goes to a private clinic to get the best care.
    Those without money wait, and often die or suffer.
    I think citizens here need a wake up call. If we switch systems, there will be an appalling DECREASE in healthcare quality, in exchange for a small INCREASE in healthcare access.
    Not a good trade.

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