Potential solutions to the copayment dilemma

June 30, 2008

A general policy of copayments or top-ups, allowing patients to pay privately for drugs, would be counter to the principles of the NHS and grossly unfair to desperately sick people, say experts on BMJ.com today.

"Once a policy is introduced for one disease, where will the process stop? It could come in for equally unproved dementia drugs" and would be "disastrous", writes Cam Donaldson, Director of the Institute of Health and Society at Newcastle University in a Personal View. This would led to escalating costs and threaten the equity of healthcare delivery.

Professor Ilora Finlay and Professor Nigel Crisp, both independent members of the House of Lords suggest that one solution may be to produce a definitive list of drugs for which copayments would be permitted, recognising that the National Institute of Clinical Excellence (NICE) cannot always produce a quick or definitive response.

They point out that other health systems have experienced problems with copayments. For example, data published in 2004, showed that in the US, where there is widespread use of copayments, 40% of patients did not seek medical attention when they needed it because of the potential costs involved. In contrast to the UK, where the figure was just 9%, the lowest in the study.

In the UK, NICE was created to evaluate the evidence of drugs and treatments from clinical trials and decide on their use in the NHS. This takes time, and patients are increasing faced with the dilemma that despite evidence that a licensed drug has a benefit, it has not yet been appraised or funded by NICE, and if they purchase it privately, they will be excluded from NHS care.

But according to the Finlay and Crisp, in practice, the number of patients wanting to pay for additional drugs is small and most are drugs that have yet to be reviewed by NICE, or for which there is insufficient evidence of a benefit to patients.

They suggest accelerating the NICE process as much as possible and compiling a definitive list of drugs for which copayments would be sanctioned on the basis of four criteria:Patients who are unwilling or unable to participate in a clinical trial should be willing for their treatment and its outcomes to be recorded on a register to monitor adverse incidents and to be used in subsequent reviews by NICE.

A government review of whether patients should be able to remain NHS patients if they pay privately for drugs is due to report in October this year. This will not be an easy task, say the authors, it will have to tackle some difficult issues including whether copayments should cover the cost of administering drugs and any complications arising from private treatment as well as the cost of the drug itself.

Donaldson believes that to control healthcare costs and address the dilemmas posed by "budget-busting" cancer drugs, governments need to target the supply side of the market and not try to limit patient access by ineffective and unfair "user fees" that do nothing to increase access.

It is vital that patients and the public continue to be involved in making decisions about health and healthcare, says Donaldson. But, "If we want to raise money in a way that is consistent with what we want to achieve in health care, there is another way--it's called taxation", he concludes.
Professor Ilora Finlay, House of Lords, Westminster, London, UK
Tel: + 44 (0) 207 219 6693
Email: finlayi@parliament.uk

Professor Cam Donaldson, Director, Institute of Health and Society, Newcastle University, Newcastle, UK.
Tel: + 44 (0)191 222 5593 or +44 (0)191 222 3463 (PA, Anita Tibbs) or +44 (0)191 222 8761 (PA, Catherine Brennand)
Email: cam.donaldson@ncl.ac.uk

Click here to view personal view: http://press.psprings.co.uk/bmj/june/copaymentspv.doc
Click here to view editorial: http://press.psprings.co.uk/bmj/june/copaymentsed.doc


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