Thursday, March 22, 2007

Resource allocation in Healthcare

There is a very interesting article in the Globe and Mail this morning titled B.C. likened to U.S. after refusal to pay for costly treatment . The article is about the availability of the the drug Hepsera for the treatment of chronic hepatitis B. This is a treatment that has huge potential costs for the already strained health care system. Like the debate about the provision of the drug Fabrazyme for Fabray's disease this is really part of the debate about where we put our health care dollars.
In my opinion it is vitally important that we recognize that health care is a finite resource, and that appropriate resource allocation is the key to ongoing provision of publicly available health care in Canada. I'm not arguing against Hepsera (which could actually be cost saving, as hepatocellular carcinoma, and cirrhosis are expensive consequences of chronic hepatitis B), rather I am arguing for rational, and evidenced based allocation of health care resources with input from front-line health care providers but not macro allocation by front-line health care providers.
I've pasted my response to the article, as posted on the G&M website below.
This is part of a larger and more interesting question in our health care system. Where should resource allocation take place?
In the current Canadian health care system patient autonomy is held as near absolute, and many, perhaps most, Canadians feel that they are entitled to any treatment that is of potential benefit, regardless of cost. This is an issue when we look at treatments that are only occasionally required, but extremely expensive (for example Fabrazyme, for Fabry's disease) or for cheap but very widely used treatments (like statins for hypercholesterolemia).

In BC there is a hidden epidemic of chronic hepatitis B. In part due to a history of immigration from areas of south east Asia where Hep B is endemic, there are estimated to be about 40,000 people in the BC lower mainland with chronic hepatitis B. All of these people are at risk for hepatocellular carcinoma (liver cancer) and cirrhosis. Currently no organized program exists to provide all these patients with follow-up (regular ultrasounds, and alpha-fetoprotien measurements), never mind to treat all of them.
The issue here is the cost of the potential 40,000 people who would benefit from treatment. The question is complex, because we must recognize that as a resource, health care, in the broadest sense, is finite. Spending money on any treatment means not spending money on another treatment. More money for one disease means less for another disease, or for public health programs, or for early childhood nutrition programs, or for something else.
As a doctor, I recognize that I may not be the best person to make decisions of resource allocation. I am generally focused on the patient in front of me, and charged to act as their advocate. I will almost always recommend what is best for them personally first and for society second. That being said, I recognize the vital importance of thoughtful, evidenced based resource allocation. In our strained system, where that occurs is a vital debate.

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