tag:theconversation.com,2011:/us/topics/doctor-54053/articlesdoctor – The Conversation2023-08-04T12:30:37Ztag:theconversation.com,2011:article/2098102023-08-04T12:30:37Z2023-08-04T12:30:37ZCollege students with loans more likely to report bad health and skip medicine and care, study finds<figure><img src="https://images.theconversation.com/files/539773/original/file-20230727-29-hz1qlc.jpg?ixlib=rb-1.1.0&rect=70%2C151%2C7629%2C4428&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A new study found that those with student loans are more likely to delay medical, dental and mental health care. </span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/burnout-anxiety-and-fatigue-creative-student-royalty-free-image/1445373401?phrase=college+students+mental+health">PeopleImages/iStock via Getty Images </a></span></figcaption></figure><p><em>The <a href="https://theconversation.com/us/topics/research-brief-83231">Research Brief</a> is a short take about interesting academic work.</em> </p>
<h2>The big idea</h2>
<p>Students who took out loans to pay for college rated their overall health and mental health as being worse than those who didn’t take out student loans. They also reported more major medical problems and were more likely to report delaying medical, dental and mental health care and using less medication than the amount prescribed to save money. </p>
<p>We <a href="https://doi.org/10.1080/07448481.2022.2151840">reported these findings</a> in an article published in the Journal of American College Health. The findings are based on surveys collected in 2017 from over 3,200 college students at two public universities in the United States.</p>
<p>We asked students to rate their physical and mental health on a 4-point scale – excellent, good, fair and poor. We also asked if they had experienced any major medical problems in the past year or whether they had ever postponed medical, dental or mental health care to make ends meet since starting college. Those who indicated they were taking regular medication for physical health problems, such as for asthma or high blood pressure, were asked if they ever took less medication than prescribed to save money. </p>
<p>Students with loans reported worse outcomes than those without loans, even after accounting for differences between them in terms of race, age and gender, as well as their parents’ education level and marital status.</p>
<p>Despite their worse self-reported mental health, students with loans were equally likely as students without loans to have received a new mental health diagnosis or treatment for a mental disorder in college. They also were equally likely to have visited a mental health practitioner in the past year or to use mental health medication. But they were almost twice as likely as those without debt to report delaying mental health care. </p>
<h2>Why it matters</h2>
<p>Our findings suggest that student loans may have hidden costs in the form of worse physical and mental health, more medical problems and diminished use of medical and mental health care. Stress from student loans <a href="https://eric.ed.gov/?id=EJ1141137">can affect students</a> while they are still in college, <a href="https://doi.org/10.1037/cdp0000207">harming both mental and physical health</a>.</p>
<p>College students are often at a <a href="https://doi.org/10.1037/11381-002">crucial juncture</a> when they are first leaving their parents’ home and <a href="https://doi.org/10.1038/oby.2008.365">establishing habits</a> – such as those related to medical and dental care – that may persist beyond college. Declining to seek medical care <a href="https://doi.org/10.1016/j.jchf.2021.05.010">can result</a> in <a href="https://doi.org/10.7326/0003-4819-114-4-325">worse medical problems</a>, potentially leading to diminished health and shorter lives for college graduates with loans.</p>
<p>One of the advantages of getting a college degree is <a href="https://doi.org/10.2105/AJPH.2011.300216">improved</a> <a href="https://www.forbes.com/sites/michaeltnietzel/2019/06/17/new-evidence-for-the-broad-benefits-of-higher-education/?sh=a4e88834c5c1">health</a>. But students who take out loans to attend college may not see those benefits, especially if they defer medical care or use less medicine to save money.</p>
<p>Previous generations had greater access to free or low-cost <a href="https://press.jhu.edu/books/title/12165/history-american-higher-education">public higher education</a> – access that has eroded as state budgets <a href="https://doi.org/10.1525/ctx.2009.8.1.76">failed to keep up</a> with the <a href="https://www.acenet.edu/Documents/Anatomy-of-College-Tuition.pdf">rising demand for and costs</a> of higher education. The current system of higher education funding <a href="https://educationdata.org/student-loan-debt-statistics">requires most people to take on debt</a> to get a college degree; the <a href="https://ticas.org/affordability-2/student-aid/student-debt-student-aid/student-debt-and-the-class-of-2019/">most recent national data</a> indicates that among 2019 graduates of public or private nonprofit, four-year universities, 62% had student debt.</p>
<h2>What’s next</h2>
<p>We are writing a book that explores how debt affects life after college, including the consequences for health, housing, romantic relationships and career trajectories. So far, we have found that inequalities in health and delays in doctor visits persist after graduation. We have also found that college graduates who put off doctor visits to save money in college were a little over twice as likely to experience a recent major medical problem 15 months and 3.5 years after graduation. We also found they were over four times as likely to be be putting off medical care to save money after graduation, showing these habits persist well after they leave college.</p><img src="https://counter.theconversation.com/content/209810/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Arielle Kuperberg receives funding from the National Science Foundation. </span></em></p><p class="fine-print"><em><span>Joan Maya Mazelis receives funding from the National Science Foundation.</span></em></p>College students who postpone medical care to save money end up paying for it down the line in the form of worse health, a researcher contends.Arielle Kuperberg, Professor of Sociology, University of North Carolina – GreensboroJoan Maya Mazelis, Associate Professor of Sociology, Rutgers UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1397412020-06-02T12:17:25Z2020-06-02T12:17:25ZAmericans’ deepening financial stress will make the coronavirus a lot harder to contain<figure><img src="https://images.theconversation.com/files/338914/original/file-20200601-95009-izeanw.jpg?ixlib=rb-1.1.0&rect=229%2C0%2C5234%2C3645&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A growing number of Americans are feeling financial stress and unable to afford basics like food and health care.</span> <span class="attribution"><span class="source">AP Photo/Marcio Jose Sanchez</span></span></figcaption></figure><p>Preventing deaths from COVID-19 depends on people who get it <a href="https://theconversation.com/what-coronavirus-symptoms-should-i-look-for-and-when-do-i-call-the-doctor-a-doctor-answers-4-questions-133676">seeking treatment</a> – which also allows authorities to track down whom they came in contact with to reduce spread. </p>
<p>But, as the <a href="https://www.reuters.com/article/us-usa-economy/new-wave-of-us-layoffs-feared-as-coronavirus-pain-deepens-idUSKBN2340E6">economic pain</a> and joblessness caused by the statewide lockdowns continue to grow, more Americans are experiencing severe strains on their personal finances. This threatens our ability to contain the pandemic because those feeling the most financial stress are much less likely to seek medical care if they experience coronavirus symptoms, according to my analysis of a <a href="https://www.federalreserve.gov/publications/2020-economic-well-being-of-us-households-in-2019-description-of-the-survey.htm">recent Federal Reserve survey</a>. </p>
<p>As an <a href="https://publicpolicy.umbc.edu/david-salkever/">economist who studies how individuals make health care choices</a>, I worry that in the coming months even more people will consider forgoing vital treatment to pay rent or some other bill – especially as the extended unemployment benefits, rent moratoriums and other relief <a href="https://www.marketwatch.com/story/ending-the-extra-600-a-month-americans-are-getting-in-unemployment-benefits-could-cost-the-us-more-jobs-some-economists-say-2020-05-28">are set to expire</a> soon.</p>
<h2>‘Just getting by’</h2>
<p>The Fed <a href="https://www.federalreserve.gov/publications/2020-economic-well-being-of-us-households-in-2019-description-of-the-survey.htm">conducts a survey</a> of the economic health of U.S. households every quarter, most recently near the end of 2019. In April, it conducted a supplementary but similar survey to quickly gauge how people were handling the coronavirus crisis. Results of both surveys were released on May 14.</p>
<p>The Fed tries to measure financial stress in three key ways. Its surveys ask respondents if they are unable to pay all their monthly bills, couldn’t cover a US$400 emergency expense, or are “just getting by” or worse. </p>
<p>Even before the pandemic hit, the picture wasn’t pretty. In October, when the fourth-quarter survey was conducted, 42% of employed respondents reported fitting at least one of these descriptions, while over 8% said they fit all three. Those figures jumped to 72% and 20% for low-income workers. </p>
<p>But by April, tens of millions of people who had jobs in October lost them as most nonessential businesses across the U.S. either closed or reduced their services. The <a href="https://data.bls.gov/timeseries/LNS14000000">unemployment rate shot up to 14.7%</a> that month – the highest since the Great Depression – and is expected to climb further when the May data are released on June 5. </p>
<p>The Fed’s April survey, however, paints an even broader picture of the economic impact of the pandemic. In that survey, about 28% of the previously employed respondents said they either lost their job, were being furloughed, had their hours cut or were taking unpaid leave. This has been financially devastating to many, with 68% of this group reporting one of the stresses listed above and 28% saying they were experiencing all three, regardless of income level. </p>
<h2>Forgoing medical care</h2>
<p>Separate questions in the surveys demonstrate just how strong the link is between financial and physical health.</p>
<p>The October survey also asks those respondents if they had skipped a doctor’s visit during the previous 12 months because of the cost. More than 20% of those who reported one of these financial stresses said they had, while almost 46% of those with all three said so. </p>
<p><iframe id="9Si5W" class="tc-infographic-datawrapper" src="https://datawrapper.dwcdn.net/9Si5W/1/" height="400px" width="100%" style="border: none" frameborder="0"></iframe></p>
<p>In April, the Fed asked a more timely question: “If you got sick with symptoms of the coronavirus, would you try to contact a doctor?”</p>
<p>A third of those respondents who also said they’re experiencing all three financial stresses said “no.” This is especially significant because, unlike the October question, it describes a current, known threat, rather than referring to a previous medical issue of unknown severity. And the widely reported urgency and seriousness of the coronavirus suggests someone wouldn’t treat the decision to seek a doctor’s care or advice lightly. </p>
<h2>Relieving the stress</h2>
<p>That was back in April, less than a month into the coronavirus lockdowns. If the same questions were asked today, I believe the numbers would look a lot worse. </p>
<p>In the middle of a serious pandemic, we don’t want sick people avoiding treatment because they’re worried they won’t be able to put food on the table. This would likely worsen the spread of the <a href="https://www.cdc.gov/coronavirus/2019-ncov/if-you-are-sick/steps-when-sick.html">coronavirus</a> and make it a whole lot harder to contain. </p>
<p>As <a href="https://ktla.com/news/nationworld/congress-debates-whether-to-go-big-on-next-coronavirus-relief-bill-or-hit-pause/">Congress debates</a> additional measures to mitigate the economic and financial effects of the pandemic, it would be wise to keep in mind the connection between financial stress and individual decisions to seek medical care. </p>
<p>[<em>You’re smart and curious about the world. So are The Conversation’s authors and editors.</em> <a href="https://theconversation.com/us/newsletters?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=youresmart">You can read us daily by subscribing to our newsletter</a>.]</p><img src="https://counter.theconversation.com/content/139741/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>David Salkever does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>A third of Americans experiencing significant financial stress say they wouldn’t contact a doctor if they experienced coronavirus symptoms.David Salkever, Professor Emeritus of Public Policy, University of Maryland, Baltimore CountyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1230892019-09-12T20:04:52Z2019-09-12T20:04:52ZWomen may find it tougher to get an abortion if the religious discrimination bill becomes law<figure><img src="https://images.theconversation.com/files/292115/original/file-20190912-190050-umpo22.jpg?ixlib=rb-1.1.0&rect=7%2C7%2C991%2C784&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Women may need to shop around for a new doctor if the first one refuses to perform an abortion for religious reasons.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/confident-successful-young-businesswoman-short-hairstyle-712523149?src=E06daX2sOMd7UbakC2nXjA-1-49">from www.shutterstock.com</a></span></figcaption></figure><p>If the <a href="https://www.ag.gov.au/Consultations/Documents/religious-freedom-bills/exposure-draft-religious-discrimination-bill.pdf">Religious Discrimination Bill</a> passes into law, women may find it harder to get an
abortion. </p>
<p>That’s because health practitioners with an objection to performing the procedure on religious grounds may have stronger legal protection and may not be compelled to refer women to an alternative provider.</p>
<p>This may lead women to consult multiple services, if available, before finding a doctor willing to perform the procedure.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/the-government-has-released-its-draft-religious-discrimination-bill-how-will-it-work-122618">The government has released its draft religious discrimination bill. How will it work?</a>
</strong>
</em>
</p>
<hr>
<h2>Who does the bill cover and where?</h2>
<p>In the new bill, the term “health practitioner” has a broad meaning. It includes doctors, nurses, midwives and pharmacists. If the bill passes into law, it would apply to health practitioners around Australia. This means it has the potential to override current state and territory laws protecting women seeking abortions. </p>
<p>At the moment, in states such as <a href="http://www.legislation.vic.gov.au/domino/Web_Notes/LDMS/LTObject_Store/ltobjst10.nsf/DDE300B846EED9C7CA257616000A3571/E8DB0BF2182A7CEFCA2582CC00130DDA/$FILE/08-58aa005%20authorised.pdf">Victoria</a> and <a href="https://www1.health.nsw.gov.au/pds/ActivePDSDocuments/PD2014_022.pdf">NSW</a>, health professionals may conscientiously object to performing abortions but must refer women to another service.</p>
<p>However, this new bill may override state laws by allowing health professionals with a conscientious objection to refuse to refer them.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/one-in-six-australian-women-in-their-30s-have-had-an-abortion-and-were-starting-to-understand-why-111246">One in six Australian women in their 30s have had an abortion – and we're starting to understand why</a>
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</em>
</p>
<hr>
<p>The bill may also restrict the ability of private hospitals or private clinics to enforce a workplace policy that requires health practitioners to refer patients to other health practitioners if they object to abortion themselves.</p>
<p>If the new bill becomes law, the only situations where the health professional would be compelled to provide an abortion is if his or her employer would suffer “unjustifiable adverse impact” or if the patient would suffer “unjustifiable adverse impact”. </p>
<p>It is unclear how the courts will interpret these rules. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/factcheck-do-women-in-tasmania-have-access-to-safe-abortions-92173">FactCheck: do women in Tasmania have access to safe abortions?</a>
</strong>
</em>
</p>
<hr>
<h2>The new bill may make existing matters worse</h2>
<p>The bill may also exacerbate problems some women already face in accessing an abortion.</p>
<p>For instance, in Tasmania, <a href="https://www.buzzfeed.com/ginarushton/this-woman-paid-thousands-of-dollars-to-fly-interstate-for">some</a> <a href="https://www.smh.com.au/lifestyle/life-and-relationships/faced-with-an-unplanned-pregnancy-angela-had-difficult-decisions-to-make-20190306-p51244.html">women</a> <a href="https://www.abc.net.au/news/2019-03-06/abortion-provider-still-not-operating-in-tasmania/10875438">are forced</a> to travel to Victoria due to the difficulty of accessing medical practitioners to perform the procedure in their home state.</p>
<p>In 2018, a Cricket Australia employee Angela Williamson <a href="https://www.theguardian.com/australia-news/2018/jul/30/woman-cricket-australia-sacked-abortion-rights-tweets">spoke out</a> after being forced to travel from Hobart to Melbourne for this reason. After speaking out on Twitter about the poor access to abortion services in Tasmania, she lost her job.</p>
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<h2>Conscientious objection is already a problem</h2>
<p>Not all doctors act legally under existing legislation. A <a href="https://bmcmedethics.biomedcentral.com/articles/10.1186/s12910-019-0346-1">recent study</a> focusing on Victorian providers found doctors had:</p>
<ul>
<li>broken the existing law by not referring women to another provider if they objected to perform an abortion</li>
<li>attempted to make women feel guilty about requesting an abortion</li>
<li>attempted to delay women’s access to abortion services, or</li>
<li>claimed an objection for reasons other than conscience. </li>
</ul>
<p>The study also showed how government phone staff authorising abortion pills, pharmacists, institutions like private hospitals and political groups all used or misused conscientious objection. They either delayed or blocked access to existing services or contributed to the actual lack of abortion providers and services, via lobbying the public or government. </p>
<p>The study found misuse occurred partly because people do not have to justify or register their conscientious objection. So there is no way of knowing if someone’s conscientious objection is a genuine or deeply, consistently held religious position.</p>
<p>The new bill will likely make these types of situations more common.</p>
<h2>Right to religious freedom vs right to health care</h2>
<p>The bill <a href="https://www.theguardian.com/australia-news/2019/aug/29/religious-discrimination-bill-coalition-accused-of-weakening-state-human-rights-law">is controversial</a> because it elevates the protection of religious freedom above other rights, such as the right to health care for women seeking an abortion.</p>
<p>Hugh de Kretser, executive director of the Human Right Law Centre, <a href="https://www.hrlc.org.au/news/2019/8/29/concerns-over-proposed-religious-discrimination-law">says</a>:</p>
<blockquote>
<p>Australia needs stronger protections from discrimination for people of faith, but the current bill introduces unjustified carve-outs for people to express discriminatory views and to override state and territory protections which ensure fair treatment, particularly for women accessing abortion services.</p>
</blockquote>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/religious-discrimination-bill-is-a-mess-that-risks-privileging-people-of-faith-above-all-others-122631">Religious Discrimination Bill is a mess that risks privileging people of faith above all others</a>
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</em>
</p>
<hr>
<p>Adrianne Walters, senior sawyer at the Human Rights Law Centre, <a href="https://www.hrlc.org.au/news/2019/8/29/concerns-over-proposed-religious-discrimination-law">says</a>:</p>
<blockquote>
<p>The bill will undermine women’s reproductive health. In some jurisdictions, like South Australia and Western Australia, it will allow doctors to abandon their patients. The bill unjustifiably prioritises a doctor’s personal religious beliefs over the right of women to access the healthcare they need. </p>
</blockquote>
<p>In 2018, an International Women’s Health Coalition <a href="https://iwhc.org/resources/unconscionable-when-providers-deny-abortion-care/">study</a> found a failure to provide abortions to women has terrible impacts by placing “patients at risk of discrimination, physical and emotional harm, and financial stress”. Those possible harms included death.</p>
<h2>What we’d like to see</h2>
<p>The Religious Discrimination Bill should be amended to strike a better balance between religious rights and women’s right to access abortion. It is important to require conscientious objectors to refer the patients seeking abortion to other providers. </p>
<p>There should also be provisions in the bill to ensure conscientious objectors genuinely have deeply and consistently held religious positions, perhaps through a registration scheme.</p><img src="https://counter.theconversation.com/content/123089/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Doctors who won’t perform abortions on religious grounds may have stronger legal protection and may not be compelled to refer women to an alternative provider. Here’s why that’s bad news for women.Elizabeth Shi, Lecturer, Graduate School of Business and Law, RMIT UniversityAriella Gordon, Research assistant, Graduate School of Business and Law, RMIT UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/965622018-05-31T13:11:32Z2018-05-31T13:11:32ZUK spends generously to extend lives of people with terminal illnesses – against the public’s wishes<figure><img src="https://images.theconversation.com/files/219955/original/file-20180522-51095-20z8b8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-illustration/heart-pulse-monitor-flatline-raster-version-87801649?src=2fR2njpIEc8B5gFq7pitTw-1-60">Tripplex</a></span></figcaption></figure><p>When deciding which treatments publicly funded healthcare systems should provide, medicines that extend terminally ill patients’ lives are among the most hotly debated – particularly for advanced cancer. </p>
<p>The National Health Service (NHS) spent an <a href="https://www.england.nhs.uk/publication/next-steps-on-the-nhs-five-year-forward-view/">estimated</a> £17 billion on medicines in England in 2016-17, roughly 13% of its budget. This was up from £13 billion in 2010-11, with the medicine bill <a href="https://www.kingsfund.org.uk/publications/rising-cost-medicines-nhs">currently increasing</a> at over 5% a year as <a href="https://files.digital.nhs.uk/publication/n/1/hosp-pres-eng-201617-report.pdf">new drugs</a> get ever more <a href="http://www.cancerresearchuk.org/funding-for-researchers/research-features/2016-08-10-health-economics-the-cancer-drugs-cost-conundrum">expensive</a>. </p>
<p>Underlying this is a controversy many people probably aren’t aware of. The relevant authorities – the National Institute for Health and Care Excellence (<a href="https://www.nice.org.uk">NICE</a>) in England and Wales, and the Scottish Medicines Consortium (<a href="https://www.scottishmedicines.org.uk">SMC</a>) north of the border – take a more generous approach to approving end of life drugs than all other drugs. </p>
<p>Yet according to our research, most people are not in favour. This raises searching questions about why it happened and what to do in future. </p>
<h2>NICE numbers</h2>
<p>NICE was first set up in 1999 (and SMC in 2001) to determine the availability of different drugs and treatments nationally, thus ending postcode prescribing. </p>
<p>The two agencies decide which drugs to make available by looking at how many <a href="https://www.nice.org.uk/glossary?letter=q">quality-adjusted life years</a> or QALYs the average patient will gain from them. QALYs are calculated by multiplying how much a given treatment will lengthen a patient’s life by how much it will improve the quality. </p>
<p>You can then work out the “cost per QALY” by dividing the additional cost of the treatment by the number of QALYs gained. This is used to compare how much different treatments will improve patients’ health, per pound spent. For more explanation, watch this video:</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/wtmz0hhxrV4?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
</figure>
<p>When NICE and SMC were set up, they both introduced a <a href="https://www.nice.org.uk/process/pmg9/chapter/the-appraisal-of-the-evidence-and-structured-decision-making">threshold</a> of £20,000-£30,000 per QALY, above which medicines are unlikely to be recommended. This presented problems for new end of life drugs, with <a href="https://www.bmj.com/content/355/bmj.i5792">their</a> high prices and limited information about effectiveness. </p>
<p>The government was also under political pressure following <a href="https://www.telegraph.co.uk/finance/personalfinance/insurance/3378442/Victory-for-cancer-patients-as-NHS-ban-on-top-up-drugs-is-lifted.html">media reports</a> about cancer patients using life savings to buy drugs unavailable on the NHS. New Labour “cancer tsar” Mike Richards <a href="http://www.idsihealth.org/wp-content/uploads/2016/02/A-TERRIBLE-BEAUTY_resize.pdf">recommended</a> making an exception to the general threshold. NICE duly <a href="https://www.nice.org.uk/guidance/gid-tag387/documents/appraising-life-extending-end-of-life-treatments-paper2">introduced</a> supplementary guidance in 2009, which set an <a href="https://pharmaphorum.com/articles/end-of-life-treatments-what-will-nice-accept/">effective threshold</a> of £50,000 <a href="https://jamanetwork.com/journals/jama/article-abstract/2671713">per QALY</a> for medicines which extend life for at least three months. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/221014/original/file-20180530-120499-l13gli.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/221014/original/file-20180530-120499-l13gli.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/221014/original/file-20180530-120499-l13gli.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=429&fit=crop&dpr=1 600w, https://images.theconversation.com/files/221014/original/file-20180530-120499-l13gli.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=429&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/221014/original/file-20180530-120499-l13gli.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=429&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/221014/original/file-20180530-120499-l13gli.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=539&fit=crop&dpr=1 754w, https://images.theconversation.com/files/221014/original/file-20180530-120499-l13gli.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=539&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/221014/original/file-20180530-120499-l13gli.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=539&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Are all QALYs equal?</span>
<span class="attribution"><span class="source">www.joelcooper.co.uk</span></span>
</figcaption>
</figure>
<p>In 2011, the Cameron government launched a special Cancer Drugs Fund (CDF) for England to enable still more patients to access cancer drugs not (or not yet) approved by NICE. The CDF’s cost per QALY threshold <a href="https://www.ncbi.nlm.nih.gov/pubmed/27565274">was estimated</a> to be over £200,000 per QALY. The body was overhauled in 2016 because spending was getting out of hand, having spent a total of £1.3 billion on cancer drugs for 95,000 patients. </p>
<p>Nonetheless, QALYs gained through life extensions for terminally ill and cancer patients remain more highly valued than QALYs for everyone else – <a href="https://www.nice.org.uk/Media/Default/About/what-we-do/NICE-guidance/NICE-technology-appraisals/process-and-methods-guide-addendum.pdf">at least 1.7 times more</a>. Senior figures at NICE and the CDF have justified this by <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2949905/pdf/bcp0070-0346.pdf">claiming that</a> the public places <a href="https://www.bmj.com/content/349/bmj.g5545">special value</a> on extending lives. But does this stack up? </p>
<h2>Public opinion</h2>
<p>Previous studies show <a href="https://www.sciencedirect.com/science/article/pii/S0277953618301035?via%3Dihub">mixed results</a> on public values in this context: eight out of 23 found that end of life health gains were valued more; 11 found the contrary, while another four were equivocal. This probably reflects differences in study design, but also suggests people are highly conflicted. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/219963/original/file-20180522-51105-7vwho1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/219963/original/file-20180522-51105-7vwho1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/219963/original/file-20180522-51105-7vwho1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=390&fit=crop&dpr=1 600w, https://images.theconversation.com/files/219963/original/file-20180522-51105-7vwho1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=390&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/219963/original/file-20180522-51105-7vwho1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=390&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/219963/original/file-20180522-51105-7vwho1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=490&fit=crop&dpr=1 754w, https://images.theconversation.com/files/219963/original/file-20180522-51105-7vwho1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=490&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/219963/original/file-20180522-51105-7vwho1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=490&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">What the public thinks.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-vector/illustration-group-demonstrators-protesting-perspective-color-739326304?src=0nBmitHjAP0pe-Pjg7-iBQ-1-1">rob zs</a></span>
</figcaption>
</figure>
<p>We sought to find out more. Where most studies focused on the choices respondents would make (for themselves or for society), we also looked at what people believed. We did this in three stages over a number of years. </p>
<p>First <a href="https://bmcmedethics.biomedcentral.com/articles/10.1186/s12910-015-0008-x">we sought</a> the views of 59 specialists, including academics, clinicians, people working in the pharmaceutical industry, patient families and health policy makers; plus a sample of 250 members of the public. </p>
<p>They each had to arrange 49 statement cards on a grid, placing those they most agreed and disagreed with at either end. Examples were, “Treatments should be directed towards people who have a greater chance of survival”; and “We should support an individual patient’s choice for treatments that give short life extensions”. </p>
<p>Three viewpoints <a href="https://bmcmedethics.biomedcentral.com/articles/10.1186/s12910-015-0008-x">emerged</a>:
</p><ul>
<a href="https://vimeo.com/productionattic/review/116354862/712ea88720"></a><li><a href="https://vimeo.com/productionattic/review/116354862/712ea88720"><strong>Viewpoint 1</strong></a>: Maximise health gain across the population to give best value for money overall, making no special case for end of life medicines. Many of the new cancer medicines therefore wouldn’t be provided;</li>
<a href="https://vimeo.com/productionattic/review/116354863/0a8a227bbd"></a><li><a href="https://vimeo.com/productionattic/review/116354863/0a8a227bbd"><strong>Viewpoint 2</strong></a>: Don’t deny treatments because of cost – prioritise patient rights and entitlements, not value for money. We should pay to extend lives, but all patient choice matters, not only terminally ill people; </li>
<a href="https://vimeo.com/productionattic/review/116354872/0c9ac890cf"></a><li><a href="https://vimeo.com/productionattic/review/116354872/0c9ac890cf"><strong>Viewpoint 3</strong></a>: Costs and benefits are key, as in viewpoint 1, but we should include non-health benefits like time to set your affairs in order. Sometimes even short life extensions are worth it, but it should be about quality of life and death, not extending life at all costs. </li>
</ul><p></p>
<p>We <a href="https://onlinelibrary.wiley.com/doi/full/10.1002/hec.3640">then designed</a> an online survey to test the prevalence of these views more widely. From nearly 5,000 respondents, 37% most agreed with viewpoint 1, 49% with viewpoint 2 and 9% with viewpoint 3 (the remaining 5% had mixed views). This mixed response echoes <a href="https://www.kingsfund.org.uk/publications/does-public-see-tax-rises-answer-nhs-funding-pressures">other population surveys</a>.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/220647/original/file-20180528-80626-1g90g1z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/220647/original/file-20180528-80626-1g90g1z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/220647/original/file-20180528-80626-1g90g1z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/220647/original/file-20180528-80626-1g90g1z.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/220647/original/file-20180528-80626-1g90g1z.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/220647/original/file-20180528-80626-1g90g1z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/220647/original/file-20180528-80626-1g90g1z.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/220647/original/file-20180528-80626-1g90g1z.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">What the doctor ordered.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/white-medical-pills-on-colored-background-651760954?src=XFkX9G8vnGWzir94u3m-LA-2-7">evkaz</a></span>
</figcaption>
</figure>
<p><a href="https://www.sciencedirect.com/science/article/pii/S0277953617307499?via%3Dihub">Finally</a> we asked 1,496 respondents to choose between policy options a national body like NICE must make, and treatment choices to reflect trade-off decisions made by regional health boards with fixed budgets. </p>
<p>Just 4% supported the options closest to NICE policy, and only 6% prioritised the equivalent treatment. Far more supported policies (32%) and treatments that improved quality of life (43% for end of life and 51% for non-terminal conditions).</p>
<h2>What this means</h2>
<p>Clearly NICE is out of step with public opinion – even if it’s not simple to make policy recommendations to reflect the views we found. When people did back paying more for end of life medicines, it was not to extend lives but to improve quality. This might imply shifting resources from expensive cancer drugs towards palliative and social care services. </p>
<p>The findings also raise questions about why the disparity between public and policy exists: is it government by headlines? Is it because industry lobbyists are being listened to instead? At the same time, if pharmaceutical companies made new medicines cheaper, these would meet the general QALY thresholds and none of this would matter. That key issue doesn’t receive enough attention from politicians or the media. </p>
<p>This much is clear: there is a gap between what the public thinks and the official approach to end of life medicines. We should recognise this and reflect on where we go from here.</p><img src="https://counter.theconversation.com/content/96562/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Rachel Baker received a grant from the Medical Research Council to cover research from 2011-14. </span></em></p><p class="fine-print"><em><span>Helen Mason received a grant from the Medical Research Council to cover research from 2011-14. </span></em></p><p class="fine-print"><em><span>Neil McHugh received a grant from the Medical Research Council to cover research from 2011-14. </span></em></p>New findings show what the public really thinks about how we prioritise treatments at the end of people’s lives.Rachel Baker, Professor of Health Economics, Director Yunus Centre for Social Business and Health, Glasgow Caledonian UniversityHelen Mason, Professor of Health Economics, Glasgow Caledonian UniversityNeil McHugh, Research Fellow, Health Economics, Glasgow Caledonian UniversityLicensed as Creative Commons – attribution, no derivatives.