Transcript Anaesthetic management of pulmonary hypertension
Challenges and opportunities in New Zealand’s pharmaceutical scene Kevin Sheehy – Chief Executive, Medicines New Zealand Dalton Kelly – Chief Executive, New Zealand Cancer Society Assoc. Prof. Ken Whyte – University of Auckland Medical School
Changes & opportunities in NZ Pharmaceutical Scene: An individual clinician’s view.
Ken Whyte Respiratory, Transplant & Sleep Physician
Demographic time bomb
Christensen K et al, Lancet 2009;374:1196
Increasing demands: kidney dialysis projections
Pharmac & NZ successes
Controlling pharmaceutical spending For majority of conditions has delivered adequate therapies & benefits at reduced cost Developed a “commercial” model that both sides (funder & Pharmaceutical Industry) understand Clinicians griped but could live with system for most therapies – system struggled with genuinely “new” therapies and high cost treatments.
Pharmac overall has “Brownie points” in the bank with the health system (providers/funders/users)
Pharmac & NZ weaknesses?
Treasury small – Health budget finite Minimal resource for health economic analysis: Poor costing data for NZ health & disability costs Total lack of University health economic departments to train & offer analytical resource for Pharmac/Industry/Government/Patient groups Pharmac very limited resource ( MOH similar) Failure to debate the ethics of health funding and delivery.
Ethical approach – not clear?
the greatest good for the greatest number The worst off have no priority
(Rawls – Justice as Fairness) to the greatest benefit of the least advantaged, open to all under conditions of fair equality of opportunity
In health care (+/- social care) – should a life saving or altering therapy, (even if very expensive) take priority over treating a lesser problem in a larger number?
Variety of tools tried to measure but crude tools in reality & struggle to assess life altering/saving therapies.
Precedent, equity & transparency – if one high cost treatment funded ($/QUALY) then others of same benefit should be funded
The Clinician’s dilemma
Advocate for individual patient In rare or very disabling conditions often no other advocates for the patient group Awareness of resources and societal demands Pharmac’s response: Exceptional circumstances Now named patient approach (NPPA) from 1/3/12 In past no clear societal decision in health funding re Utilitarianism versus more “graded” approach
Break down of the Pharmaceutical model:
In short term many therapies will come off patent so $$$ looks good Large pharmaceutical companies portfolios shrinking Small niche companies (often funded by venture $$) targeted & often “individual” therapies (small volume & great cost) Shrinking room for Pharmac to trade over a portfolio to allow new therapies affordable entry in NZ
Dramatically life altering & saving replacement therapies
This leads to an increasingly complex and probably insoluble dilemma around allocation of resources.
Orphan diseases*: rare, yet many (estimated 5000-7000) & both randomised trials and cost benefit analysis not feasible as such small numbers – yet up to 2+% of population suffer when all added together!
* life-threatening or chronically debilitating diseases which are of such low prevalence that special combined efforts are needed to address them
(progressive muscle weakness leading to disability & death): algluosidase alfa drug, Lumizyme© - “adult” $250,000 per year for initial improvement & slowing of progression Societal costs of care altered by therapy?
Cystic Fibrosis – disabling, fatal 25-40yrs with very poor quality of life & huge cost: For some sufferers – prospect of replacement therapy from infancy with dramatically altering life quality & expectancy: Therapy for life - ?1-75 yrs Cost versus benefit – normal versus disabled life.
Go forth and multiply?
Triumvirate of material scientists/smart engineers/health scientists near limitless “new” developments Rapid redundancy – limited time for trials Traditional RCT model difficult: Placebo difficult Time frames to assess QALY often long Cost benefit analysis for in-patient devices (theatre, wards etc) differ for individual services & different hospitals.
“Publicly” funded utility trials rather than manufacturer funded?
Pharmac & NZ future?
Pharmac model needs to be pro-active & change before “melt-down” & loses credibility?
Pharmac taking on Medical devices maybe a step too far?
Pharmac has always been under-resourced (proud & lean is not always productive!) NZ Society has to debate the ethics & make decisions – Pharmac can only delay