Friday, 19 June 2009

Half-baked Beans - or How crazy can we get

The Price of Life on BBC2 was fascinating. It dealt with Lenalidomide for Myeloma. Initially NICE decided that the drug was too expensive, about £47000 for each QALY saved. After the initial NICE decision the drug company Celgene offered a new deal. If the NHS will pay for the first two years of treatment then the company will pay after that if the patient survives. As a result of this seductive offer NICE has approved the drug.

If the drug does not work and the patient dies before two years are up then the NHS pays. Usually when I buy something that does not work I expect to get my money back, in other words the company pays. This deal is thus the opposite of normal commerce.

If the drug does work the company will pay after the patient has survived two years. Presumably they still expect to make a profit so how much must they be making in the first two years in order to afford to give it away after that?

There are a variety of estimates available as to how long patients might expect to live but one paper that was touted by supporters of the drug last year said 5.6 years (Abstract #0441 European Haematology Association 13th Congress June12-15 2008 Copenhagen Denmark). So that means that when the NHS pays for 2 years the company must still expect to make a profit when it pays for another 3.6 years. Assuming that they have built in a bit of a margin for error we have to assume that at least half of the current price is profit. Isn’t that a bit steep? If they had aimed at 10% profit instead then the price would have fallen below NICE’s threshold.

If that is not bad enough, there is an even more dire possibility. Maybe the company knows that the drug doesn’t usually achieve much; in which case they can breath easy that they will make a fortune on the majority of patients who die before the two years are up, and they will pay for the occasional patient who survives against the odds.

This deal must be about the most crazy that the NHS has ever done. The NHS will pay for drugs that don’t work and the company will pay when they do. Is that how we mean to go on? In effect it encourages drug companies to make drugs that don’t work and charge ridiculous amounts for them. Surely we should have done the deal the other way around and offered to pay after two years if the drug company would pay for the first two. That way the drug company only make money if the drug really works.

One thing the TV programme does make clear is that it wasn’t NICE’s idea to do this deal, the offer was made by the company and the Government told NICE that they could not negotiate, so it was the Government who said yes to this half-baked scheme.

You might think that the secret that the drug does not save many people would come out. Think about it, the only people who will live to tell the tale are the occasional patients in which it does work. Of course those who do survive will think it is a miracle and no doubt we will see them in the media telling everyone about it. We won’t see interviews on the TV from the patients who did not survive. I suppose it could get even worse if the survivors thank the drug company for giving them their ticket to life and at the same time the relatives of those who die sue the NHS for providing them with a drug that didn’t work.

I now plan to market a new kind of baked beans, called half-baked beans, which I will say are a great cure for terminal disease. I will charge a great deal for my half-baked beans. When people take them, there are three possible outcomes: (1) they will die; (2) stay the same; or (3) live. If they die, I will say, ‘If only we had started sooner’. If they stay the same, I will say ‘Keep taking the half-baked beans’ (and paying me lots of money). Eventually all these patients will fall into groups I or 2. If they get better, I will say that the half-baked beans did the trick.

I will, of course, make the government a generous offer that I will pay for the half-baked beans for anyone who survives more than two years provided that the government pays for all the other patients.

Anyone wishing to buy shares – the usual brown paper envelope will suffice.

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