samedi 19 septembre 2015

Cancer and economics

1/ "Most of all, health expenses increase because of the impact of chronic diseases like diabetes or cancer."
This assumption is simply false. Expenses increased but depending on several factors including diabetes, cancer and other consumptions... Magnitude of the welfare state is of critical importance in this analysis. It explained the wide differences between global amount of expenses among the different countries.

2/"Health expenditures are rising very quickly in nearly all rich countries where they represent between 8% and nearly 20% of the GDP."
More exactly it is 8-16% of GDP. And the most interesting fact is that these expenses do not correlate with LE!

3/ "Some economists have argued that the pharmaceutical market for anti-cancer drugs was not perfectly efficient. Proof is that the increase in price is not justified by inflation and the survival benefits."
The price is influenced by the R&D process which is very costly due to all regulations in Europe, salaries, contracts, high cost of labs and high cost of bureaucracy to fill the process of regulation agencies approval. The only good point which slightly counterbalances those inflating factors is the cost of borrowing which is maintained at a very low level by central banks (

4/ "Third, even if the unit cost of the treatments declines, their rate of diffusion will soar so that the global cost will continue to increase exactly as we saw in the past with coronary stents in heart diseases." 
Comparison with coronary stents is not valid. First the diseases is completely different because the cause is well known in CHD (blocked coronary arteries by atherosclerosis) and is ignored in cancer. Second the use of CS is widely different among cardiology teams and even in the same team among cardiologists. Chemos indications are very pretty the same all over the world. CS are over used because we are dealing with small arteries which are imaged on movies of the beating heart rather than hemodynamic measurable factors. It will change when those data will be available as with FFR. Chemos are used only for cancer patients when the diagnosis is certain.

5/ In this setting the different solutions which are proposed missed the point. The great weakness of healthcare systems in Europe is the lack of market based mechanisms. Monopolies, state based systems are debt addict or impose rationing. The recent example of the german healthcare system is enlightening because it combines market incentives and mechanisms with insurance and a safety net. This system has no financing problems.
Indeed all the systems have to prioritize the allocation of resources to efficient treatments instead of reimbursing a wide range of services which are far from evidence based. Instead public healthcare systems are managed to avoid social clashes with employes and to maintain old rules of reimbursement especially for hospital stays. The connection with politicians leads to delay any change and consequently to a crowding effect within a constrained budget.

6/  Cancer is mainly and always a scientific challenge. It is not the role of healthcare systems to deal with this issue. R&D both public and private is benefitting of the huge amount of research all over the world. But there is a lack of competition and concurrence in a lot of allocation processes especially in countries where research is state owned and financed. A fierce darwinian process is mandatory for allocating funds if we want to hasten arrival of disruptive treatments of cancer. We cannot rely on private research only, that is why we need to improve the efficiency of university research and to increase the participation of hospitals in clinical trials. 

We are not in a battle or war against cancer. This "progressist" vision is a failure since its birth in the Nixon's policy of 1971 (
Cancer is an enigma. We are searching to solve it. That is the issue and it has not to be mixed or balanced with other problems at the risk of jeopardizing scientific solutions. Especially cancer research has nothing to share with access to care which is very well solved by market mechanisms and a mandatory but strictly necessary amount of taxing for those who cannot afford an insurance premium.

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