TFRI National Dialogues

Mr. Chris Skedgel- Monday, April 12th, 2010




List of Atlantic Dialogue Speakers
(Organized by Core Issues)
    Core Issue #1: Cancer Care & Population Health: Core Issue #2: Cancer Care & the Health System: Core Issue #3: The Science Behind Cancer Care:
    Ironically, after everyone has been speaking about cost, I want to speak about value and outcomes. I'm struck by how Kara's discussion of personalized care, and what she called stratified care, fits with the current trend in economics, towards what we can call 'personalized evaluation'.

    Health economic evaluation had concentrated on survival. Then we made a conceptual breakthrough and started to consider quality alongside survival. The most recent breakthrough is the idea that instead of thinking generically about drugs, or thinking generically about diseases, maybe we need to start thinking about the individual patients themselves. And while I'm certainly not saying more patients are more deserving than others, some patients may have characteristics that society values differently. So while it would be fantastic if we could give every patient all the care they need, everyone understands that resources are limited and that demand will always be greater than supply so we need to consider how we allocate our limited health care resources.

    In other markets - forgetting health care for the moment - we distribute things by price. We as a society have decided that that is reasonably fair. If I have more money to spend on a television, I can get a bigger television than someone else. But in Canada we have decided that this is not a fair way to distribute healthcare. In the US, they have said "yes, the price mechanism is a reasonable way to allocate healthcare", but in Canada, we have said no, we want to go about allocating healthcare differently. Sometimes we say that we want to treat the sickest patients: the sicker you are, the more care you are entitled to. And I think everyone in the room would say, "that seems reasonable, that seems fair", but at the same time, we might say we also want give care based on how well someone can benefit from that treatment. If we have, for example, a ninety year old with a bad back, cataracts and heart disease, he's probably not very high on the list of people we would give a knee replacement to. On the other hand, if we have a 19-year-old girl with juvenile arthritis and who otherwise has a long healthy life ahead of her, we may say she has priority over the 90 year old for the knee replacement. I think we would say "that's reasonable and fair." But now we have said "the sicker you are, the more care you deserve" and at the same time we have also said "the less sick you are, the more care you deserve". So the question health economics is trying to grapple with is how do we resolve these inconsistencies in how we are allocating resources? The thinking in health economics these days is that there are a lot of different facets in what we as society value in healthcare. Sometimes we value the fact that it will help the sickest patient; sometimes we value the fact that it can extend life the furthest. At other times it may be that relative value is based on the age of the patient or the patient's responsibility for their disease. In this sense we're moving away from simply evaluating a whole population, defined by the drug or the disease, to evaluating individual patients based on their characteristics.

    To conclude, I am struck by how well these two movements in economics and medicine are coming together - in terms of talking about personalized care and personalized evaluation. The challenge ahead of health economics now is to identify just which facets of healthcare society values and what relative weights should be applied to these different characteristics.