"If You're Happy and You Know It"

Remember the Bible School song, "If You're Happy and You Know It, Clap Your Hands"? In the UK government-controlled health care system, this little song is not just for children in Sunday School. All ages should take the advice of the song because a demonstration of happiness is one of the government's tests to qualify citizens to receive the healthcare they need.

The gatekeeper to the UK National Health Service (NHS) is its National Institute for Health and Clinical Excellence, known better by the wonderfully Orwellian acronym, (NICE). America's left insists that moving to a European-style health care system would not ration or deny health care based on the infamous "pre-existing conditions." However NICE in the UK is openly tasked with doing just that. They directly affect your quality of life, for instance, by helping determine its proper length. The QALY (quality-adjusted life year) is the tool for attaching value to the years you have left. One factor being the determination of how you might enjoy those years.

No one knows exactly how NICE determines the QALY, nor can they. It depends on their mood and yours--seriously. NICE candidly admits that in addition to a quantitative component, completely qualitative measures such as mobility and intensity of pain are factored--which of course are not "measurements" at all. Your "mood" affects your QALY score.

Before you pass this off as just a neo-conservative bloviation that would never take place in the U.S., consider a topic called Comparative Effectiveness Research (CER), the U.S. version of NICE. CER was funded in the stimulus bill to the tune of $1.1 billion.

The Congressional Budget Office defines CER as, "...a comparison of the impact of different options that are available for treating a given medical condition for a particular set of patients." The CBO goes on to note, "The analysis may focus only on the relative medical benefits and risks of each option, or it may go on to weigh both the costs and the benefits of those options."

The cost priority is consistent with the UK NICE philosophy. Alan Maynard and Karen Bloor write an editorial in the "Journal of the Royal Society of Medicine," stating, "NICE has been parsimonious in its referral of unproven products for more research evidence, and should perhaps be more robust with industry, requiring it to provide good evidence of cost-effectiveness or face rejection of NHS reimbursement." Maynard and Bloor go onto write about patients with HER-2 breast cancer. These are patients with a more rare type of breast cancer that are sometimes prescribed trastuzumab (Herceptin). The authors note this treatment is, "clinically effective only for a subgroup of patients..." However, Maynard and Bloor state, "Again, the central issue is demonstrable cost effectiveness rather than special consideration."

There are two major problems with the philosophy that Maynard and Bloor advocate:

1) The central issue in health care should not be costs. In the U.S., the primary issue in healthcare is to provide the best medical outcomes possible. This might just be the reason people like the Saudi Prince come to the U.S. for surgery. While costs do need to be addressed--and can be without rationing care--they should not be the central issue that determines the care individuals receive.

2) The focus on groups of patients is directly comparable to CER where benefits are analyzed, according to the CBO, "for a particular set of patients." However, U.S. personalized medicine is not a "one size fits all" approach. Individual patients respond differently to different treatments or may have different preferences regarding treatment. Making coverage decisions based on group studies is not quality care.

So if you're happy and you know it, clap your hands and say so--it could be the difference between going to the hospital and going to hospice. Apparently, the grumpy need not apply.