Is Pharmac's decision not to prioritise funding melanoma drug Keytruda a case of “putting money before people”, or is it the inevitable outcome of making rational choices with limited resources?
Yesterday, in part one, Bryce Edwards looked at The case for Keytruda. In part two he looks at the case for Pharmac’s independence, and therefore against the immediate funding of Keytruda.
Who among us could refuse desperate cancer patients begging to have access to a potentially life saving drug? Not their families and friends, not the wider public and certainly not politicians. Politicians can be all of those things – cancer patient, family, friend – and they must also contend with intense public pressure and the siren call of votes.
That’s precisely why Pharmac is so important, say its supporters. It’s seen as a useful mechanism to rationally make good public health medicine funding decisions without the influence of emotion or even populism contaminating a good process.
Back in December Kevin Hague summed it up by saying: “There is always more demand on the health dollar than there is dollars to spend. That is why we have a system, reasonably free of political interference, that buys the most drugs at the best price to provide to the most number of New Zealanders. It is a system that by and large works and we support keeping it that way” – see: In defence of Pharmac. He says the main problem is “the pharmaceutical budget simply isn’t big enough, and is declining in real terms because of the underfunding of DHBs.”
In Hague’s view, the alternative is that we have dishonest debates where politicians are happy to ride in on their white horse but will not take responsibility for the repercussions of their actions. He says that’s what’s happening in the Keytruda debate and what’s missing is the acknowledgement that “If $30Mn is spent every year on Keytruda, it won’t be available for other people with different conditions, on drugs for which it says it has better evidence of health gain.”
It’s a point echoed by James Dann earlier this week: “the people who aren’t in this equation are the people whose treatment would have to be defunded. This is a zero sum game, and to fund one treatment, you have to defund another… To pitch one group with disease A versus a group with disease B would be an horrific spectacle, if we did have to watch it play out in public. So we don’t. We trust that a group of medical and pharmacological experts will weigh up all of the evidence, and come to conclusions for us” – see: Keytruda, Pharmac, and the zero sum game of drug funding. Dann argues “The political debate around this should focus on the amount we spend on drugs, not which specific drugs are funded.”
Writing in this week’s Listener, Jane Clifton says we are faced with the “dismaying prospect of reducing drug funding to a beauty parade. If politicians keep acceding to public campaigns by groups of particular patients, the health system could degenerate into a sick parody of X-Factor, with one illness lobby competing on the steps of Parliament to be more appealing than another.”
For more on why Pharmac should be trusted to make drug buying decisions see the Herald editorial, Govt ought to keep clear on medicines.
While not all clinicians seem to agree with Pharmac’s initial decision on Keytruda, the University of Otago’s Tony Blakely provides some in depth cost-benefit analysis in support – see his blog post, Is Keytruda for advanced melanoma cost-effective? Applying the BODE3 rapid cost effectiveness calculator.
Labour’s political interference
Labour has been on the receiving end of a wave of criticism this week for it’s pledge to overrule Pharmac and fund Keytruda if elected. Hague is strongly critical of Labour’s proposal saying “we have been there before” with National’s 2008 campaign to increase funding of Herceptin. He argues that “political interference almost always ends up in less health gain, not more.”
In his column today in the NBR Matthew Hooton writes: “Against much competition, opposition leader John Key’s intervention in 2008 on behalf of Herceptin ranks as perhaps the most disgracefully cynical stunt in recent political history but opposition leader Andrew Little may have trumped him with Keytruda.”
In his column, King tarnishes reputation over Keytruda at end of career (paywalled) (http://bit.ly/HootonKeytruda), Hooton takes special aim at Labour’s health spokesperson Annette King who he believes is selling a new stance that she doesn’t actually believe in. He also argues that if Pharmac’s decision on Herceptin and Keytruda were flawed then a different approach is necessary: “a sensible policy response would be either to dramatically increase the funding or reform the model.”
Tracy Watkins also says that Cancer sufferers should not be used as a political football. Watkins decries the “political point scoring” and says science is being overrun by “naked politics”. She declares that “No one's hands are clean in the Keytruda row – not Labour's, for coat tailing the plight of vulnerable cancer patients to attack the Government. Not the drug companies, for which the political heat is useful leverage for driving up the price in their negotiations with Pharmac. And not National, for preaching the moral high ground despite creating an uneven playing field in the first place by running similar interference in Opposition over breast cancer drug Herceptin.”
A further condemnation of Labour’s “extreme new policy” is provided by Newstalk ZB’s Larry Williams, who says “This is deceitful. Labour have never funded drugs on that basis. Never. Now, all of a sudden, after a secret meeting with Big Pharma, they're going to fund the latest state-of-the art drugs. Cost is no longer an issue, seemingly. Political interference in drug selection is clearly foolish” – see: Cancer drug debate not solved by wild spending.
The National Government’s political interference
Indications are that National is buckling under public pressure over Keytruda. Previously steadfast Health Minister Jonathan Coleman pledged earlier this week to “make the case” for extra funding for Pharmac in the May budget. See his interview with Paul Henry: Labour pushing Govt to fund life-saving drug.
RNZ’s health correspondent Karen Brown later said it’s “not usually a promise you hear out loud from a government ahead of a budget” – listen to Brown’s interesting five minute discussion with Guyon Espiner: Funding of cancer drug Keytruda. She believes that Coleman’s admission that National was “wrong” to overrule Pharmac over Herceptin was more an admission of a “political mistake” as “once against they’re under pressure and this time they’re on the other side of the equation.”
Yesterday the Government continued to tie itself in knots with Edwin Mitson reporting Coleman told a conference of GPs, pharmacy professionals and consumers that funding for melanoma treatment is "not too far away", while simultaneously insisting the decision is up to Pharmac – see: Health Minister: Melanoma treatment funding not far off.
Vernon Small says oh to be a “fly on the wall” when those discussions take place, as with no “directive from the Government, Pharmac may not in the end choose Keytruda – or for that matter any other drug to treat late stage melanoma – if it has higher priorities. However, you can be fairly certain that the Government will be moving heaven and earth to ensure it does” – see: Labour may not like it, but private dinners with drug lobbyists is a valid news story.
In fact, National appears to have been leaving themselves wiggle room to repeat their Herceptin performance for some time. Back in December, before her reinstatement to cabinet, Judith Collins dropped hints on the Paul Henry show that the Government may yet fund Keytruda. Key himself has admitted their current hands-off Pharmac stance could be seen as “hypocritical”, while at the same time repeatedly refusing to rule out funding Keytruda.
The politics of “big pharma”
In the words of Vernon Small, opening the door of political meddling with Pharmac “merely invites in the lobbyists.” Gareth Morgan agrees, saying with customary bluntness “We need to bear in mind that Pharmac are negotiating with profit seeking companies here. The more politicians meddle with that, the more the drug companies will milk it. In other words if we keep throwing money at this problem, they will keep putting their prices up” – see: Pharmac and the Crazies: John Key admits mistake, Andrew Little looks to repeat it.
Morgan also argues that “our drugs bill will explode” if politicians “keep running interference in order to covet special interest votes”. He concludes: “Unless taxpayers are happy to fund every drug on earth at any price, politicians need to get back in their cages, let Pharmac do its job of allocating the budget. The only political decision should be the size of their budget.” See also Gareth Morgan’s A letter to Annette.
David Farrar pointed out last year that the actions of National over Herceptin and Labour over Keytruda “both play into the hands of large multinational pharmaceutical companies who learn that whipping up public support for a drug is a better method than convincing scientists and doctors that the benefits of a drug outweigh the costs” – see: Hague is right.
On Tuesday the Greens’ Kevin Hague was under attack for suggesting that political interference based on public pressure “sets up pharmaceutical companies to fund marketing campaigns which potentially could exploit people who are already the victims of these diseases to become lobbying pawns for industry" – see Simon Wong and Laura Macdonald’s Hague slated for 'despicable' drug lobbying comment. Lisa Renwick called Hague’s comments “despicable”, rejecting any suggestion she is involved with drug companies.
In his column, Big Pharma winners from Keytruda stoush, Barry Soper says Renwick “doesn't see herself as a guinea pig but as a survivor, and who can blame her?” but he says by virtue of her dependence on Keytruda to stay alive, she is essentially forced into assisting the drug company.
This week Stacey Kirk reported that “Drug company lobbyists were hosted at a special dinner by Labour leader Andrew Little, months before Labour announced its stance to override Pharmac and fund melanoma drug Keytruda” – see: Andrew Little dines with drug company executives months before adopting Keytruda stance.
Kirk points out that Labour’s stance is a “u-turn on its position during the widely publicised Herceptin debate in 2008.” But Little rejects any suggestion that Labour’s decision was influenced by drug companies, or notion of political donations being a factor. Kirk’s report also noted rumours that there are “significant ructions” forming within Labour over its political interference with Pharmac.
Following up on this, Vernon Small says “Labour's reaction to Fairfax reports of a private dinner leader Andrew Little hosted with Medicines NZ (the lobby group set up and peopled with senior figures from the pharmaceutical industry) and of disquiet in the party, was visceral.” Well, Small says, Labour may not like it, but private dinners with drug lobbyists is a valid news story.
Blogger No Right Turn says FFS Labour, arguing that meeting with the pharmaceutical industry inevitably taints the party and gives the impression of “corporate shilling.”
And for more on all these issues, especially in terms of background information on Keytruda and the pharmaceutical industry, see Gordon Campbell’s On Pharmac’s unequal battle over the funding of Keytruda.
Finally, Danyl Mclauchlan argues National’s strategic acumen is largely based on a “willingness to break with political conventions when it is tactically advantageous to do so.” In doing so National has unleashed an arms race scenario and Mclauchlan argues no one should be surprised to see Labour now doing the same over Keytruda because: “Having opposition parties that are constrained by conventions but a government that breaks them whenever its convenient isn’t a thing” – see: Drug funding and political conventions.
