Critics charge list ignores common conditions and that decision-making process is vague and faulty.
By JUDY SIEGELmedicine 248.88(photo credit: Ariel Jerozolimski)
The public committee for recommending drugs and new indications to be added to the government-subsidized "health basket" in 2009 produced a list of about 70 after a 20-hour discussion that ended on Friday morning.
While the new drugs and indications, worth a total of NIS 415 million, are meant to help 340,000 patients, critics said the list will disappoint many people and that the method of choosing additions is faulty.
The drugs recommended for inclusion are prescribed for neurological, psychiatric, gastroenterological, genetic, hematological, oncological, cardiovascular, gynecological, lung, ophthalmological, rheumatological, orthopedic, dermatological nephrological, urological and infectious diseases, as well as diabetes, HIV, organ transplants and infant nutrition.
The public committee initially examined 437 candidate drugs or indications, narrowed the list and then chose the final ones in an argumentative hearing, the last of many held over the past few months.
The committee is chaired by Prof. Menachem Fainaru, former dean of Tel Aviv University's medical faculty, and includes 18 members who serve on an unpaid basis.
The additional drugs will be provided, starting in 2009, at nominal cost to health fund members, thanks to the NIS 415m. Treasury subsidy.
Formally, the list has to be okayed by the health and finance ministers and approved by the National Health Council (which meets on Wednesday), but they generally rubber-stamp the committee's recommendations.
The final list will be published on the Health Ministry's Web site - www.health.gov.il - after it is formally approved.
Critics include Avi Raz, who owns and operates the famed Alba pharmacy on Jerusalem's Jaffa Road and has worked as a pharmacist for over 58 years. He told The Jerusalem Post after the list was made public that it doesn't offer much new.
This year's list includes drugs that were already provided voluntarily at nominal cost by some of the health funds to their members because the funds recognized that they were cost effective, maintained Raz.
Adding these drugs to the basket would mean the health funds would be compensated for them, but it did not offer much of the public anything new, he said.
Committee sources, however, said that the health funds often changed their decisions on what drugs and indications they gave voluntarily, while the new list required all funds to provide them permanently.
But Raz noted that preventive treatments that would have a wide impact on public health - such as drugs that help smokers kick the habit - were not included in the list.
The list overrepresents drugs for transplant patients and for diabetics dependent on insulin, Raz said, and ignored vital oral drugs for much more common conditions, such as Type II (adult-onset) diabetes.
For example, Byetta, a non-insulin but very effective injected diabetes drug needed by many of the country's 400,000 diabetics, was not included, Raz said.
Raz said his son Prof. Itamar Raz - head of the Hadassah University Medical Center's Diabetes Center, president of the Israel Diabetes Research Group, head of the Health Ministry's National Diabetes Council and former president of the Israel Diabetes Association - spent two hours before the basket committee recommending oral diabetes drugs.
In the end, they did not approve any, apparently because there are so many who need them that the cost would be enormous, Raz said.
The Jerusalem pharmacist, who graduated from the Hebrew University School of Pharmacy in 1950, said a type of eye drops given after cataract surgery recommended for the list "costs only NIS 25 and will be provided to an estimated 108,000 people."
But anyone can afford them, he said, so it was a waste of money to add this drug to the basket. Yet the large number of recipients of a cheap drug "create a good impression," Raz said.
"Last year's basket expansion list was much better," Raz maintained.
In addition, the disease indications for some new drugs are so narrow that only a handful of patients will get them. These include Nutren Junior for feeding 90 children suffering from metabolic or neurological disorders and Prevnar vaccine against pneumonia for 30 infants with ataxia telangiectasia.
While this lifesaving vaccine is routinely given to healthy infants in the US and other countries, it is not included in the vaccinations financed separately by the Health Ministry's own budget.
Avishai Zohar, the spokesman for the basket committee, said the members - who include representatives of the Finance and Health ministries, senior physicians and the public - "worked according to professional, ethical and moral considerations and an effort to balance public needs within existing limitations."
Raz also criticized the health funds' allocation of the drugs.
Once the four health funds receive the list of state-subsidized drugs they have to provide to relevant members, "their bureaucrats look at dry criteria rather than at the person behind it and try to go according to the strictest criteria. Instead, more autonomy should be given to the physician who knows the patient and insists he needs a drug," Raz insisted.
"In the UK, every National Health Service district is offered an annual drug budget and is free to choose which patients most need available drugs. The social needs of the patients are taken into consideration, but this is not a consideration in the Israeli system," Raz maintained.
The Israel Medical Association (IMA) has long fought for a automatic annual two-percent increment in the basket to replace the unilateral decision by the Treasury how much to expand the basket each year. This technique would significantly expand the number of drugs covered by the health funds.
"Because of the lack of transparency, one can only guess how the [Health Ministry's] medical technologies administration [which prioritizes the candidate medical technologies for the basket committee] manages to meet this almost impossible mission" of choosing the new list, said Dr. Philip Sax, editor of the Pharma journal and an independent researcher and analyst of drug policy and economics.
"It may be that the administration does not seriously consider all 437 medical technologies but only chooses some of them in some kind of hidden process," Sax continued. "It may be that the ministry does examine each technology, but due to the limited time at its disposal and the curtain of secrecy in which it works, it is not clear how serious this examination is."
Sax noted that the IMA abandoned its membership in the public basket committee and set up its own (non-binding one) to produce an alternate list, but only 50 percent of the drugs on the official list were on the IMA recommended list.
Sax added that there were many drugs that did not cost more, as they replace older drugs that were no longer used. Some drugs actually saved money for the health funds, hospitals, National Insurance Institute and employers, but these savings were not taken into consideration when including them in the NIS 415m. addition to the basket.
He concluded that the decision process is "accelerated and superficial" to prevent the interference of vested interests and political considerations - but it raises questions about the quality of the final decisions on updating the basket.
In addition, said Sax, the ministry did not periodically reexamine the basket of heath services. As a result, some services that were less cost-effective remained in the basket and continued to get state subsidies.
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