Fair care?

The recently published edition of the Swedish Cancer Society Report for this year has reviewed target attainment by the county councils for some cancer diagnoses. Unfortunately the analysis points to a poor outcome: public healthcare is unable to meet the need. The report is also interesting to read in the light of recent debate on co-financing and self-financing of care.

There has been specific focus on self-financing and cofinancing of life-sustaining treatment in recent times. The Swedish National Council on Medical Ethics (SMER) some time ago presented a report on self-financing and co-financing. Co-financing relates to the situation where a patient funds part of the medical care not covered by the publicly financed provision. SMER notes that co-financing already exists. This means that in some cases patients are able to choose a more expensive product and bear the additional costs themselves. This may be the case in connection with cataract operations or a more expensive hearing aid than covered by the publicly financed models. But this is also the way the market for generic medicines works, where the patient has the right to choose a more expensive alternative.

The issue come to a head when serious conditions such as cancers are involved. In recent times the issue of unequal access to the prostate cancer drugs abiraterone (Zytiga) and enzalutamide (Xtandi) has been the subject of public debate.

We know that new cancer drugs contribute to prolonged survival and improved quality of life. The Swedish Society of Medicine’s delegation for medical ethics recently established that the right cancer medicine can prolong survival, alleviate pain and generally contribute to an improved life situation in the form of fewer disease symptoms. In our work for the pharmaceutical industry we quite often observe that the Dental and Pharmaceutical Benefits Agency (TLV) has come to the conclusion that a particular medicinal product is not regarded as cost-effective and that the product has therefore been excluded from the pharmaceutical benefits scheme. The health service in turn tries to bypass TLV by making its own direct purchases in order to make it possible for the medicines to be provided and for patients to receive appropriate care. It has become evident in the debate that TLV has a too strict a financial approach and that the agency neglects the right to care according to need which is, in fact, one of the basic tenets of Swedish legislation. The cancer drugs Zytiga and Xtandi are estimated to cost around SEK 1000 per day of treatment and patient. It is not reasonable for patients with such a common cancer diagnosis as prostate cancer to be deprived of the most appropriate and modern treatment due to a relatively manageable increase in cost, particularly in view of the fact that the total cost of medicines has decreased in recent years. 

It is naturally reasonable in this context to imagine that patients are willing to contribute to the cost of a more expensive drug treatment themselves, a wish that appears eminently understandable. Is it then right to deny patients what in reality is a better life on the grounds of what have been claimed in the debate to be reasons of equity? 

This is obviously a highly complex issue. But it can also be questioned whether the prevailing system, with a somewhat parsimonious attitude to patients’ right to contribute to their medical care is right and correct. Why should substitution of a generic medicine be regarded as more reasonable than the case where someone wants to receive the best cancer treatment, perhaps even life-saving better treatment? If the healthcare system, including TLV, cannot be organised in such away that it provides appropriate and modern care, I for my part consider that co-financing in many cases appears both humane and desirable.

Life Science Report has spoken to Magnus Pettersson, Country Manager, Astellas Pharma AB. He has made the following comments: With regard to co-financing, I will be thinking about the aspects of equity, solidarity and equality. Increased influence with more power for patients may look very different depending on place of residence. I can already see great regional differences between the county councils today in the way they choose to treat with these medicines. Prostate cancer is the disease of the ageing male. This leads to both age and gender perspectives and highlights the complexity of the other considerations to be taken into account by the authorities. When I draw comparisons with other countries I fail to see a mentality and tradition of “we’ll sort it now and then solve it”, primarily for the best of the patient. A 100% watertight solution need not be directly ready, but early access for patients would be desirable, during the time the process is under way. The need and wishes for co-financing would then diminish and quicker, more humane are would be the outcome.