The Conundrum of Clinically Meaningful Benefit
The Conundrum of Clinically Meaningful Benefit
Dr. Miller: There is another financial aspect to this, one that has less of an impact on practice for you, Ian, in Canada. Besides regulatory approval, there are various insurance policies and payers who make decisions about what they are willing to cover. Even with a thoughtful doctor and a well-informed, careful patient, their decisions can be limited by what payers will cover. Do the inequity in access to care and the inability to make those decisions at a very personal level trouble you?
Dr. Tannock: It would trouble me much more if I were an American. We set the bar too low to allow registration of many drugs. We move to mega-trials because our regulatory authorities won't accept small increases as long as they are significant in the endpoint. That has led to a number of drugs that are available, with very minimal clinical benefit against a small population of select patients in trials that I suspect would have no benefit when translated into the general community with more problems.
I would set the bar higher and have fewer drugs. In the United States, rationing of medical care is a very bad thing. I think rationing of medical care is inevitable wherever you are. One cannot sustain the increasing costs of medical care that are taking place at this time, or if you do sustain it, you will have to pay for it by having the education of your children suffer because there is only a certain amount of money to go around, be it a private or public purse. We have a socialized system; that's a bad word in the States, but I like our system. It's not perfect, but it is more equitable, and we fund medications on the basis of demonstrated benefit and, to some extent -- with more marginal drugs -- cost benefit. Although that can be difficult with some patients, it is an appropriate and acceptable way to manage medical care for most of the population.
Dr. Miller: Just to be clear, we do ration care in the United States based on where you live, where you work, and what insurance plan you have. We just don't call it that.
Dr. Tannock: But it's better to have some formal guidelines. You will never have total equality of care, but it is something that we should aim for.
Rationing on Both Sides of the 49th Parallel
Dr. Miller: There is another financial aspect to this, one that has less of an impact on practice for you, Ian, in Canada. Besides regulatory approval, there are various insurance policies and payers who make decisions about what they are willing to cover. Even with a thoughtful doctor and a well-informed, careful patient, their decisions can be limited by what payers will cover. Do the inequity in access to care and the inability to make those decisions at a very personal level trouble you?
Dr. Tannock: It would trouble me much more if I were an American. We set the bar too low to allow registration of many drugs. We move to mega-trials because our regulatory authorities won't accept small increases as long as they are significant in the endpoint. That has led to a number of drugs that are available, with very minimal clinical benefit against a small population of select patients in trials that I suspect would have no benefit when translated into the general community with more problems.
I would set the bar higher and have fewer drugs. In the United States, rationing of medical care is a very bad thing. I think rationing of medical care is inevitable wherever you are. One cannot sustain the increasing costs of medical care that are taking place at this time, or if you do sustain it, you will have to pay for it by having the education of your children suffer because there is only a certain amount of money to go around, be it a private or public purse. We have a socialized system; that's a bad word in the States, but I like our system. It's not perfect, but it is more equitable, and we fund medications on the basis of demonstrated benefit and, to some extent -- with more marginal drugs -- cost benefit. Although that can be difficult with some patients, it is an appropriate and acceptable way to manage medical care for most of the population.
Dr. Miller: Just to be clear, we do ration care in the United States based on where you live, where you work, and what insurance plan you have. We just don't call it that.
Dr. Tannock: But it's better to have some formal guidelines. You will never have total equality of care, but it is something that we should aim for.
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