'Basket' case

Budgetary constraints, real and claimed, can decide which patients will live or how they will live.

pills 88 (photo credit: )
pills 88
(photo credit: )
Among the more shameful perennial pre-budget approval rites is the haggling over updating the basket of health services, including the medications which the government is prepared to fund. Here, real and claimed budgetary constraints can literally decide which patients will live or how they will live. Bureaucrats - not only professional experts - thus make decisions that determine the fates of individuals who have dutifully paid all their health insurance fees but are often let down by the system when it comes to the crunch. This year is no exception. Indeed the ritual has taken on more grotesque proportions because the 2006 budget hasn't yet been ratified, meaning that all government expenditure must, for now, be calculated in proportion to the 2005 budget. Initially, the Treasury planned for a NIS 164 million increase on 2005's outlay for medications. Sunday, the Treasury and Health Ministry agreed to raise that to NIS 310m. But this is less of an achievement than meets the eye, especially when compared with the NIS 466m. which the health basket's medical expert committee had demanded. "Basket" committee members noted, for instance, that despite the claim that Herceptin - prescribed to prevent breast cancer recurrence - is included in the basket to the tune of NIS 70m., it may not be. The caveat is that this drug must first go through the bureaucratic registration process in Israel. Even if Herceptin was authorized today, the problems surrounding it wouldn't be over. The compromise stipulates that "only women in great danger" of breast cancer relapse will be prescribed Herceptin and not women considered at lower risk. It's far from clear how one distinguishes between risk-levels and who will be in charge of making said distinction. The bottom line may be that the medication won't be available prophylactically, but only after the cancer has spread. The medical community's loudest complaint is that in the above case, as in many others, the decisions aren't medical but bureaucratic. Sunday's so-called compromise was fashioned by accountants, not physicians. The NIS 466m. package presented by the medical committee wasn't just a monetary demand but a complex tapestry of priorities and needs. Had the committee been informed that no more than NIS 310m. was available, it may have redrawn its priorities. As is, Treasury officials took on responsibilities which should rest with doctors. The basket committee members didn't take their burden lightly. Theirs was a Solomonic task which they tackled in numerous meetings, some lasting over 10 hours, to fill the basket with life-saving, preventive or pain-alleviating treatments. Their carefully conceived balance is now incontrovertibly upset. Anti-coagulation drugs will be denied to 5,000 cardiac patients. Also not included will be help for 300 prostate cancer sufferers, severe asthma patients, epileptics and children with acute growth deficiencies. And while the resultant basket's contents weren't chosen according to professional criteria, the worse news is that this year's basket is to serve as a model for 2007 as well. Treasury officials, well-meaning though they may be, can't presume to supplant medical experts. Yet as things transpire every year, it's they who ultimately call the shots, the medical community raises a hue and cry and patients - who deserve better in their hour of extreme need - are told that other expenses take precedence to their plight. There's little doubt that with enough goodwill, the wherewithal could be found for most of the committee's package. The consensus is that the economic upswing has replenished Treasury coffers. Additionally, as elsewhere in government, administrative and other waste in the health system itself isn't inconsequential. But perhaps this isn't the exclusive antidote to annual debasement. It's no accident that Israel is the only developed state to have evolved a "health basket committee." New treatments are incorporated elsewhere in the world, but without an agonizing, disgraceful bargaining process. It's high time that we too instituted a fixed annual increase in the health budget that would automatically upgrade and update what's on hand in the national medicine cabinet. A mere 2 percent yearly increment could rid us for good of this bureaucratic malaise.