How much is a life worth?
To save one person from certain death, a medical aid company says it needs to treat four late-stage skin-cancer patients with the drug Yervoy. It costs about R2m for each patient, and the success rate is 25%.
The same R8m could help a lot of other medical aid members with various ailments, making the choice of action a difficult one given finite resources and the ultimate effect on members’ contributions.
How much to spend on high-cost drugs is an issue health insurers and patient activists have grappled with for years. That is also true for well resourced state-run systems such as the National Health Service in the UK, where a government institute assesses the value for money of a treatment as well as the medical benefit it adds so that it can prioritise those treatments that boost the country’s health the most.
A possible solution touted by local medical aid companies and administrators is joint bulk buying of high-cost medicines to lower prices, but such discounts are banned in SA.
Many have called for better health policies for new drugs in line with those of both emerging markets and developed countries. Instead, the department of health has done nothing, even as personalised medicine becomes more common and drugs more niche and costly.
It is amid this stalemate that the Competition Commission has decided to charge Swiss multinational company Roche with excessive pricing for its breast cancer drug Herceptin. It made good headlines because the drug — used by about 5% of breast cancer patients — can cost R500,000 for a one-off year-long treatment.
Perhaps the commission remembered when HIV/Aids deaths were rampant and antiretroviral medicines were out of reach, and got involved.
But it’s a different world now and drugs will keep on getting more expensive as science advances. Dealing with the trend of high-cost drugs by targeting one company and demanding a huge fine is like solving a children’s puzzle by using a wrecking ball.
It only leaves destruction in its wake.
Instead, countries as diverse as Brazil, Singapore, Taiwan and the US have pharmacovigilance policies to decide whether a new costly drug, treatment or technology is worth its price tag. SA has rejected those despite pleas by experts, activists and medical schemes that have been issued for a decade now.
Pharmacovigilance does not just look at the cost of a medicine. A team would look at its value in terms of a life saved or the reduction of other costs. For example, Herceptin prevents a specific type of cancer from returning about 85% of the time. So a committee may assess the cost of treating a recurring cancer and the cost of an economically active person dying young, versus the cost of Herceptin.
Such teams create guidelines on what is worth paying for. These would help medical aids make decisions as they cannot pay up for every expensive drug, some of which cost millions of rand and add only a few months of life.
There are other ways to lower costs.
Drug companies like to set prices globally to avoid pressure from high-income countries for cheaper deals. But they help lower-income countries with bulk-buying discounts or a refund if the treatment fails. The department of health has rejected requests for such systems and refunds.
Donations to the private sector are also banned despite drug companies asking for this ban to be lifted.
The commission has now got involved and its action, however controversial, stems from inaction at the department of health. The commission says too many people are dying from cancer, but this may have more to do with inadequate care in the public health system than actions by a company such as Roche, which has broken no law.
Only two hospitals in Gauteng provide radiology services, and they cover the whole province as well as North West and Mpumalanga. The waiting list is so long that patients die before treatment. Perhaps this is what needs to be fixed before drug companies are targeted.
These pricey drugs are not going to go away because of action by the commission, but it may motivate them to avoid bringing them to SA. That will be detrimental to patients and to SA’s reputation as a place that is friendly to potentially life-saving innovation.
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