Government Approval to Subsidize TNF Inhibitors

Yesterday I read a great article about psoriasis patients in Hong Kong looking to get treatment subsidized by the government.

Previously I worked in Hong Kong for around 4 years, and they have a great health care system offering universal coverage (i.e. taxes go towards paying for healthcare treatment for all).  However like most universal healthcare systems, coverage is limited since funds are limited.  Therefore someone in government (typically a committee) will often meet and discuss the latest treatments out, or treatments pushed forward by some lobby group, and decide on whether to add it to the list of things subsidized by the government (of course I am greatly simplifying the process here!).

The committee will look at how much a treatment typically costs, the effectiveness, and the demographics of the patient group, i.e. how many people are suffering and would benefit from treatment; and also how the disease affects quality of life, i.e. the greater the degree of loss of quality of life then the more weight is given to approving subsidization.

However with psoriasis this brings a big issue.  What is that issue?  Well stating it frankly, the numbers of people suffering & debilitated by psoriasis is huge.  In large populations we are talking about millions of people.  The other key issue is that the cost of TNF inhibitor treatment for one person is very expensive.  I’ve blogged before (and you can find some typical costs in the menu) that TNF inhibitor treatment for one person for one year typically costs around US$25K (private treatment).

So how does this relate to the current situation in Hong Kong (and any other countries which governments subsidize TNF Inhibitor treatment)?  Well I believe the following:

  1. The rate of psoriasis is increasing in society due to more being triggered through diet, pollutants, stress etc.  We will not see any decrease in this (and other) auto-immune disease until there are major changes to these three items.
  2. TNF Inhibitors absolutely will improve the condition of psoriasis patients.  In my experience TNF inhibitors produce close to 100% remission for psoriasis sufferers and brings such an incredible rise in quality of life – it is nearly impossible for someone who hasn’t suffered with an obvious skin condition to understand how life changing this treatment is.
  3. Methotrexate is a terrible solution for psoriasis.  It takes so long to see any results (if any) and in my experience does not give any great result!  The patient still suffers from a lot of psoriasis and therefore continues to suffer a huge degrade in quality of life.  Added to this patients are NOT well informed that they will be required to undergo a liver biopsy!
  4. Governments have a limited healthcare budget and therefore have to choose what treatments get subsidized and which miss out.  This is further complicated by strong lobby groups and pharmaceutical companies who pressure the government to make a decision in THEIR interests and not that of society.

So imagine if you are on the committee who has to decide on how healthcare funds are allocated for treatments.  Psoriasis comes up and you look at the figures.  You see from overseas research that TNF inhibitors can effectively put psoriasis into remission and give the psoriasis patient back their life.  You see that the treatment costs will go forever and are at least US$15K per person per year (assuming the govt. can get a good discount as per the article).  You also see that the numbers of people affected by psoriasis are in the hundreds of thousands.  You look at the summary at the bottom and note that if TNF inhibitors are approved for all those that NEED them, then you will have to cut many other currently subsidized treatments in order to stay within budget.

The bottom line?  The committee takes the “safe way” out.  They don’t disapprove subsidizing the treatment (as this would give a backlash), instead they approve it but “raise the bar” for access.  They will put out propaganda stating that methotrexate works in the majority of cases (which is garbage when comparing the outcome of methotrexate treatment to that of biologics) so therefore the majority of psoriasis sufferers can be treated with that.  For the remainder, you will have many hoops to jump through before you can get approval for treatment.  This way the government can “save face” and declare that they are making this treatment “available for all” (a great campaign ad).

But wait!  The propaganda machine is already in action.  In the article dermatologist Yeung Chi-keung said this:

“Dermatologist Yeung Chi-keung said first-line treatments such as creams, exposure to ultraviolet light and oral drugs tend not to work for about 10 percent of patients, who will then require second-line drugs, which are injected.”

Which planet are talking about Dr. Yeung?  Or more accurately, who is putting money into your pocket to make such a claim?  Looks like a government plant to me.  Walks like a duck, talks like a duck….

First-line treatments such as creams and oral drugs are typically useless, and not only that, they have terrible side effects when compared to biologics!  Do no harm Dr. Yeung!  For quality of life and safety TNF inhibitors blow creams, oral drugs, and UV light out of the water.  Yes, we are aware of how the TNF inhibitors can lower immunity – however we are a smart patient group.  I notice you didn’t say anything about long term affects of steroid creams on skin, methotrexate toxicity on the liver, or skin cancer from UV light exposure.  And if you want to go on further about the immunity danger of biologics, how about comparing the death rate of psoriasis patients through infection caused by lower immunity vs. death rate by suicide of psoriasis patients driven to death from embarrassment and being ostracized from society?

Dr. Yeung is talking BS, however I believe he is indeed a government plant and is making a covert signal that they will ultimately approve the treatment for “10%” of psoriasis patients.  After the committee approves biologics and figures roll in showing only about 10% of psoriasis patients are being approved for treatment they can point back to Dr Yeung’s quote above as justification of denying up to 90% of applicants.

So overall brickbats and bouquets for Hong Kong.  Bouquets that you are approving (finally) a good treatment for psoriasis, but brickbats that you had to pull out this Dr. Yeung to make such an outlandish statement that creams, oral drugs & UV light  therapy are enough for 90% of patients.  Hogwash.

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