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Are we best served by continuing to pursue high-tech solutions for health care, or should we be allocating funding to more cost effective measures?
There is no doubt that new high-tech targeted medical treatments being introduced into 21st century health care deliver great benefits to people. As a community, their availability helps us to feel hopeful and optimistic that such treatments could be accessible to us or our families in the future. And it is important to acknowledge the professional satisfaction and feel-good emotional buzz felt by health workers when people we have come to know as patients (and their families) have their illnesses suppressed, or even eliminated, and their lives enhanced and prolonged by treatments that we have delivered.
However, novel patented treatments are almost always very expensive and require the allocation of significant resources, generate big profits for their manufacturers, and provide healthy incomes to those who administer them.
During my time as director in an expanding regional oncology service in the early 2000s, I often wondered where politicians and administrators found the money for new treatments that were being introduced. In our district management meetings, it was always made clear that every available cent was already allocated, and around the table there were so many areas crying out for resources for health care interventions of proven benefit.
Allocating finite resources
In an article published in the 16 September 2024 edition of InSight+ (here), I wrote about the opportunity costs of funding expensive new medications in a world of finite resources where someone has to pick which patients will win or lose access to health care that might change their life.
Even though Australia does manage the cost of medications (here), there has been little public discussion of the benefits of expenditure on lower-cost chronic disease and public health measures, or evidence of rigorous analysis of the opportunity costs of approval of expensive treatments for high profile diseases.
Now in early 2025, Naci and colleagues published an analysis in The Lancet of the balance between benefits that were achieved from the English National Health Service (NHS) expenditure on new drugs between 2000 and 2020, and the outcomes had that money been spent on other proven services and treatments. While some may question the use of quality-adjusted life years (QALYs) as the standardised measure of outcomes, it is hard to think of a better alternative that could be applied across the broad diversity of treatments and services that comprise modern health care.
Their analysis found that:
New drugs generated an estimated 3.75 million additional QALYs across 19.82 million patients who received new drugs recommended by NICE [National Institute for Health and Care Excellence]. The use of new drugs resulted in an estimated additional cost to the NHS of £75.1 billion…..
If the resources allocated to new drugs had been spent on existing services in the NHS, an estimated 5.00 million additional QALYs could have been generated during 2000–20. …
Overall, the cumulative population-health impact of drugs recommended by NICE was negative, with a net loss of approximately 1.25 million QALYs.
So, in England, funding the introduction of new drugs imposes a significant net opportunity cost onto the community from the denial of treatments and services known to be effective. There is no reason to think Australia would be different.
The cost of prolonged life
Over the past couple of hundred years, human ingenuity and science have delivered great understanding and appreciation of the complexity of how our bodies work and why diseases arise. Initially, most of the gains in life expectancy were the product of public health measures like public infrastructure and vaccination, but more recently we have been developing very expensive (and profitable) new technologies for managing the enormous diversity of our ailments of ageing (and very effective ways of controlling our fertility).
As we run into the wall of our biological maximum life expectancy, (an issue that I have addressed previously in InSight+ – here, here and here), further prolongation of life becomes increasingly costly.
Inevitably, life prolongation in old age means that there are more frail and elderly people with multiple co-morbidities and declining capacity to live independently. Many patients require intensive and expensive technology to maintain their biological health but do not receive services that are necessary for their social and emotional health.
The rapid growth in demand for more personal care is unfolding just as the global population is starting to decline because the total fertility rate has plummeted, with fewer and fewer people available to deliver care and other services (here and here).
So, are we best served by continuing to pursue high-tech solutions to treat biology of established diseases irrespective of the opportunity costs?
Or should we ignore the emotion and the lobbying, and allocate funding to the most cost-effective measures of disease prevention, disease management and personal care that promote quality of life across the community as a whole?
The successes of treatments that prolong life are measured by shifts in Kaplan–Meier curves and promoted by media-friendly anecdotes of survival and cure, with resourcing decisions being made on survival increases, sometimes of just a few months.
The effectiveness of behavioural modification for disease prevention, early diagnosis, and chronic disease management to prevent late consequences and/or delay age-related decline are harder to quantify. Evidence of a healthier community may only become apparent in longer term statistical outcomes such as reduced incidence of some diseases, increased healthy life expectancy, and reduced dependency ratios.
Of course, the balance of benefits could be changed by reducing the cost of new treatments and their delivery.
We cannot afford everything that we are inventing, or that we define as our “best practice” standards for care. The allocation of funds to expensive new treatments carries the invisible cost of denial of other health care activity that might have given greater benefit to more people.
Perhaps, whenever access to a new treatment is being considered, we should start by asking:
“What component of effective health care will be withheld or withdrawn to fund this change?”
Doing so should remind us that, just as with triage and resource allocation in a disaster, the unenviable duty of decision makers is to make these difficult choices of inclusion and exclusion — choosing who will and will not receive treatment.
As I read back through this article, I find myself asking:
What do the goals of our health care become when we realise that we are approaching our maximum natural life span, or are irreversibly unhealthy? And in that context and given a choice, how might our community prefer us to allocate our finite resources?
Dr Will Cairns has retired from clinical practice as a palliative medicine specialist.
The statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policy of the AMA, the MJA or InSight+ unless so stated.
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