There are topics that we consider taboo in the Czech healthcare sector. If someone accidentally gets into them and tries to explain them or discuss them publicly, they run the risk of either “righteous” public indignation, or lobbyists working in the interests of their pharma clients. That is why certain things are practically not talked about.
One of them is the treatment of rare diseases affecting children. Just the idea of a moaning child hurts not only the general public, but also the otherwise quite rational, accustomed to many things, and sometimes even cynical community of health professionals.
As a doctor who mainly cares for elderly patients, the sight of seriously ill children being treated in the Motol children’s hospital has always filled me with feelings of pity, fear and empathy. This concerned not only the children themselves, but also their parents. I’ve never been this sensitive, or rather oversensitive, with adults. I was always better able to separate rationality and emotions there.
Yes, willy-nilly we are a society that worships children more than adults, or even the old. We have one would-be rational explanation for this, which is that children have (or can have) a long life ahead of them.
In the Czech healthcare sector, we are witnessing a sharp increase in the cost of medicines that are administered only in specialized centers. They will soon amount to 40 billion crowns per year. In a large hospital, where there are more such specialized centers, it can happen that, for example, 80 percent of the cost of medicines is consumed by one percent of all patients. And every year this ratio continues to change in favor of center treatment.
In other words, this means that the costs of “ordinary” drugs against inflammation, pain or even high blood pressure are already in the absolute minority in many hospitals compared to drugs for several hundred or thousands of patients. Until recently, one dose of the most expensive drug cost a little over 50 million crowns.
The case of little Martin, for whose treatment almost 150 million crowns was recently collected, shows that the record amount has doubled. The media criticized the health insurance company, which did not want to pay for this medicine, which has not yet been reimbursed in our country. I think the criticism was unfair this time and the discussion on this topic should focus on three areas of questions.
The first is what is the price of human life in our country. And please don’t say infinite, because only someone who has never managed any budget, even their own, can short-sightedly claim that.
In the health sector, every primary minister, economic deputy, director, founder or owner of a hospital has a defined budget, and above them, health insurance companies and finally ministries and the government as a whole.
Although many do not want to admit it, there are many situations in which we simply do not have the most expensive and best treatment available, and we very carefully weigh the cost-benefit ratio for the patient in question. And that regardless of what lawyers or even constitutional judges will think about it. This is the reality, and in the decades that I have been in medical practice, it has never been different. At this point, she’s even the most generous she’s ever been in that regard.
Health economists see it their way and estimate the value of one year of quality life in our country at more than one million crowns. And that number is very important, because it subsequently enters into the process that affects the prices of medicines on our market. However, as I wrote above, those who in the past decided to make similar considerations in public were usually swept away by debaters who, although they gave vent to their emotions, never had to solve a similar dilemma in real life.
The second big question is the price of super-expensive drugs and the precedential impact of their first use. Pharmaceutical companies represent one of the most powerful segments of the world economy. A common and partly apparently true explanation for the rising prices of new preparations is the increasing difficulty of verifying the effectiveness and safety of each specific drug. It is therefore a very risky business. But if some substance already proves to be effective, then the manufacturer will do everything to maximize his profit.
Countless books and individual “case reports” have been written about such actions. It is logical – the goal of the pharmaceutical business is profit. There is nothing immoral about that. Knowing this assumption, the prices of medicines are set, which, for example, are not regulated in any way on the American market – with minor exceptions. The price is then a reflection of the ratio of supply and demand, and if there is no competitor (but rather a larger number of similar drugs), then it may happen that the price of one drug may be 50 million crowns, but the price of another may be 100 million.
And next time maybe 200 or 500 million. It’s just a matter of meeting the basic professional and bureaucratic requirements and then finding someone who needs the medicine – and making the public aware of their need. As part of doing good deeds, she arranges that the medicine is used at least for the first time. And once used, it’s on the way to other patients. The only chance to regulate the price in this case is to carefully and critically analyze the evidence on the drug’s effectiveness (it should be completely irrefutable) and look at the price of the year of quality life that the given drug will bring. Such an attitude may seem cynical to some, but it protects us from our own emotions.
The public should – and I again appeal to the reader’s rationality – realize how many human lives can be saved for similarly high sums if they invest them elsewhere in the healthcare sector.
But because we are becoming a demanding society, and moreover very media dependent, we are losing the ability to allocate financial resources so that they serve everyone as efficiently and fairly as possible.
It is then easy to be moved in accordance with this simplified vision of the world, to try to save one specific child, but not to think about other weak points of the Czech healthcare system. And that we have them.
A capable director will build a new hospital pavilion for 100 million crowns. Cardiologists implant 200 new valves into the hearts of their seriously ill patients by catheterization. And let me give you one more example. On the website of the People in Need foundation, you will learn that more children in the world die from malnutrition than in wars, and for only 365 crowns you can ensure treatment for such a child for two weeks. It is just a mathematical problem how many children People in Need would save for 100 million.
When introducing new technologies and medicines, we should not lie to ourselves that we have and will have everything that science brings within the medical budget. However, since I stated that this topic is one of the Czech taboos, we will perhaps, to the delight of the pharmaceutical companies, pretend that the problem does not exist.
However, it is clear that we should systematically address it before the price of drugs for one or two thousand patients exhausts the budget for drugs for millions of other, “less rare” patients. Therefore, it would be appropriate to involve economists, lawyers, ethicists, philosophers and, of course, health professionals in such a discussion. All possible solutions, by which I mean certain limitations, will always be painful for someone and, with a high probability, extremely unpopular.
Or let’s simplify the whole thing and introduce additional insurance for treatment in the price above a certain amount. Yes, this topic is also very sensitive, and therefore it will probably be marked as politically impenetrable. Which in translation – and with all the consequences – means that the political elites will not want to deal with it.