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Co-payment: real patient partnership or Trojan horse?

It's a hotly debated subject and individual cases make headline news. Isnít it time, asks Liz Shanahan, for pharma to accept that patient top-ups may be inevitable?

Liz ShanahanThe New Year did not start well. Just 10 days in and an influential body of MPs called on the National Institute for Health and Clinical Excellence to lower the QALY threshold. One of the House of Commons Health Select Committee's key recommendations was that the cost-per-quality adjusted life year calculation should be lowered from the current £30,000 threshold, at least in the period following the launch of a drug.

The MPs linked the proposal to the recommendation that all new drugs should be appraised by NICE between licensing and launch. A lower threshold would ensure, that only the products that are the most cost and clinically effective would be available straightaway.

The all-party committee's recommendations bring back into focus the affordability of drugs, a debate that has been unresolved for so long that patients are taking matters into their own hands - and in a novel way that is attracting attention at the highest levels. They are seeking top-up or co-payments, arrangements in which the patient buys the drug but receives the treatment free on the NHS.

Alan Johnson, Secretary of State for Health, has said that in England co-payments would see an end to the NHS' founding principles, while the DoH said it would lead to a twotier system. Co-payment arrangements are already in a mess. A woman in Cumbria was allowed to top-up while a woman in Cornwall was prevented from doing so by her PCT.

Proponents argue that co-payment in the NHS is already alive and well. They point to dentistry, optometry, prescription charges and nursing home care. It is perfectly acceptable to the government for an NHS patient to pay an NHS dentist extra for a white filling.

That leaves the harder question of equity. If NICE rules that a drug is insufficiently cost-effective and does not recommend its availability on the NHS then the patient who cannot afford a top-up agreement is hardly disadvantaged. NICE and the government cannot have it both ways.

The Saga organisation conducted a survey last year and found that half of over 50s would pay £1,500 a year in top-up payments and one in 10 would pay over £5,200. The NHS Confederation, which represents NHS Trusts, has called for clarity over top-up payments and hosted a seminar on the subject in February.

The health insurers WPA took counsel's opinion and last year launched an innovative health insurance scheme expressly to cover the top-up costs of cancer drugs. The campaigning group, Doctors for Reform, already supports co-payment.

From an industry perspective these initiatives may seem innocuous. But if it became acceptable for the NHS to allow top-up payments for cancer drugs or treatment for Alzheimer's disease, why not include most classes of drugs, whatever their cost - and why stop at drugs? It paves the way for a limited national formulary that covers all conditions and permits free, on the NHS, only low-cost, tried and tested drugs. Anyone would then be at liberty to pay more for newer, smarter, and often kinder products. Millions would be saved but innovation would be stifled, doctors would be turned into quartermasters and patients would be disadvantaged.

Many will say that the first steps down this path have already been taken. Perhaps it is time for industry to take a view.

The Author
Liz Shanahan
is managing director FD SantÈ. She can be contacted at Liz.Shanahan@FDSante.com or on +44 (0)20 3077 0477

Innovative Thinkers in healthcare PR - a special supplement from PMGroup

15th June 2008

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