President Barack Obama has proposed the creation of an Institute
for Comparative Effectiveness as a key component of an ambitious
health care reform. The institute would have the authority to
make official determinations of the clinical effectiveness and
cost-effectiveness of medical treatments, procedures, drugs, and
President Obama's initial nominee as Secretary of Health and
Human Services (HHS), former Senator Tom Daschle (D-SD), has
likewise proposed the creation of a supremely powerful Federal
Health Board, which would have similar authority to make decisions
that would be binding on health plans and providers financed by
federal taxpayers, and potentially on private health insurance
coverage. While Senator Daschle has withdrawn his
name from Senate consideration, the concept of such a board or
institute is strongly indicative of the Obama Administration's
policy orientation toward centralized health policy
The U.S. House of Representatives has just passed the $850
billion American Recovery and Reinvestment Act (H.R. 1), the
so-called economic stimulus bill, which would establish a Federal
Coordinating Council for Comparative Effectiveness Research. The
bill would provide $1.1 billion for the new council and delegate
spending authority to the HHS Secretary to investigate the
effectiveness of different drugs and medical devices. The
Senate version of the economic stimulus package contains a similar
Of course, there is no reason why private-sector or government
officials should not have access to the best information on what
works and what doesn't. Nor is there any reason why such scientific
evaluations should not be widely available to doctors and patients
alike. But studies of the comparative effectiveness of medical
devices, drugs, and technology should be conducted primarily within
the private sector, and there should be no government monopoly over
either the research or the distribution of information. The key
issue is the personal freedom of patients to be able to choose the
health care that, in the professional judgment of their doctors,
best serves their personal needs.
Focus on Medical Technology. Technology, in particular,
can be expensive. Over the past 20 years, health technology
assessment (HTA)--the synthetic coordination of information
assessing medicines and treatments--has become increasingly popular
with policymakers and legislators around the world. Advocates of
HTA invariably believe that such an approach has the capacity to
provide decision-makers in the public and private sectors with
objective information on the value of medical technologies,
devices, and medicines. Driven by concerned perceptions of
"unproven technology," "spiralling costs" and "increasing consumer
expectations," its proponents aim to produce synthesized research
information that they believe sheds light on the effects and costs
of various forms of health technology.
Such an approach, however, would guarantee the incremental
advance of government control of private medical decisions. While
formally touted as an instrument of efficiency and effectiveness,
it would distort scientific research in the service of political or
budgetary objectives while denying individual freedom of choice. In
that sense, this approach would serve as a propaganda tool designed
to legitimize anti-consumerist rationing.
Comparative Effectiveness in Health
Care: How It Started
The intellectual roots of effectiveness research can be traced
back to mid-18th century Scotland and the "arithmetical medicine"
practiced by the graduates of the Edinburgh medical school. It was
there that James Lind famously undertook a controlled trial of six
separate treatments for scurvy. During the 1830s, Pierre
Louis developed the méthode numérique in
Paris, whereby he demonstrated that phlebotomy did not actually
improve the survival rates of patients suffering from
At the beginning of the 20th century, Ernest Codman, an American
physician, founded what is today known as "outcomes management" in
patient care. Shunned by established institutions, he set up his
own unit, the End Result Hospital. In line with his teachingsand
the findings from this unit, end results were made public in
a privately published book, A Study in Hospital
Efficiency. Of 337 patients discharged from the
hospital between 1911 and 1916, Codman recorded and publicized 123
In England, the 1930s saw the development of health services
research. In a world increasingly obsessed with egalitarian
uniformity, J. A. Glover found a tenfold variation in
tonsillectomy. Subsequently, following several decades of
socialized health care in the United Kingdom, the 1970s and 1980s
witnessed the release of a range of studies that highlighted wide
geographical variations in general medical admissions including
operations such as appendectomy, caesarean section,
cholecystectomy, hysterectomy, tonsillectomy, and prostatectomy. Such
variations not only demonstrated the inequities of the National
Health Service (NHS), but also raised questions about the probity
and cost-effectiveness of many of its treatments.
Following the publication of Archie Cochrane's Effectiveness
and Efficiency: Random Reflections on Health Services in the
United States, researchers demonstrated large variations in the
rates of prostatectomy for patients with benign prostatic
hyperplasia. This work and others suggested that such
variations "meant either under-provision in some places and/or
over-provision (and possibly ineffective treatment) in others."
While "comparative effectiveness" builds on skepticism, the
investigation of variations, randomized control trials, and
cost-benefit analysis, its reviews purport to be systematic. As
such, they attempt to go beyond the more narrative-based reviews
that used to dominate the typical review article in medical
Comparative Effectiveness: The
In recent decades, health care has advanced in significant ways.
Across the developed world, not only has medical knowledge
progressed, but investment in equipment and drugs has delivered
unprecedented gains. Treatments are safer and more effective than
ever before. Quality of life and life expectancy have been
enhanced. Alongside aging populations has come the world of
ever-increasing consumer expectations.
The rapid growth of medical knowledge and technology means it is
much harder for doctors and other health care providers to keep up
to date. Indeed, the problem of information and practice
transference is rendered almost impossible by the fact that health
care is now a highly statist and corporatist venture. Today, there
is no such thing as a free market in health care, and many of the
problems popularly associated with it are in fact the result of
Today, in virtually every country in the world, health care is
heavily influenced by government policy and fosters professional
monopoly of supply and strict top-down regulation. While there is
nothing inherent in health care that guarantees such an outcome,
governments, either actively or passively, grant special
legislative favor to interest groups when it comes to people's
medical treatments and insurance.
The idea that government is intrinsically a superior agent, over
and above a spontaneous and free market, is groundless. As David
Friedman, a professor of law at Santa Clara University in
California, has argued, both the notion of market failure in health
economics and its popularity with most opinion leaders have arisen
because many health policy analysts "interpret the problem in terms
of fairness rather than efficiency." This almost unconscious
adherence to the notion of market failure in health care is rooted
the error of judging a system by the comparison between its
outcome and the best outcome that can be described, rather than
judging it by a comparison between its outcome and the outcome that
would actually be produced by the best alternative system
available. If, as seems likely, all possible sets of institutions
fall short of producing perfect outcomes, then a policy of
comparing observed outcomes to ideal ones will reject any existing
system…. The question we should ask, and try to answer, is
not what outcome would be ideal but what outcome we can expect from
each of various alternative sets of institutions, and which, from
that limited set of alternatives, we prefer.… My conclusion
is that there is no good reason to expect government involvement in
the medical market, either the extensive involvement that now
exists or the still more extensive involvement that many advocated,
to produce desirable results.
Curiously, it is within the context of government control and
anti-competitive corporatism that new and innovative medical
treatments are met with initiatives for even more rationing by
government officials, as well as other highly regulated players
including private medical insurers. In recent years, many countries
have introduced comparative effectiveness or HTA programs,
ostensibly to improve their decision-making and their allocation of
relatively scarce medical resources. In reality, many politicians
and officials have done so not least because they are trying to get
themselves off the hook of past promises they made concerning the
provision of comprehensive, unlimited, or, as in the case of the
United Kingdom, seemingly "free" health care at the point of
Since extensive government intervention has distorted health
care markets and has made it impossible for individuals to
determine a clear and transparent value of the costs and benefits
of health care technology through a normally functioning price
system, the proponents of comparative effectiveness, or health
technology assessment, have instead resorted to a predictably
pseudoscientific methodology to give their bureaucratic
determinations a sheen of objectivity. As with other forms of
centralized government planning, the practitioners of these
bureaucratic arts attempt to capture and mathematically profile and
model their assessments; in assessing health technology, they seek
"to compare and prioritize new technologies based on different
units that aggregate…benefits."
In a study of HTA for the Stockholm Network, a prominent
European think tank, research has focused on these assessments in
terms of the value of human life:
In HTA, the dominant aggregate natural unit is called
quality-adjusted life years (QALYs). Generally, QALYs factor in
both the quantity and the quality of life generated by new health
care interventions. It is the arithmetic calculation of life
expectancy and a measure of the quality of the remaining life
years…. To date QALYs are the preferred indicator of HTAs
calculations, although one may find additional tools in use by HTA
bodies such as HRQol ("health related quality of life," which
considers physical function, social function, cognitive function,
distress, pain: in brief, anything to do with quality of life),
DALYs ("disability life adjusted years"--of life lost due to
premature mortality in the population and the years lost due to
disability for incidents of the studied health condition), and
healthy-year equivalents (HYEs).
Despite the pretense of scientific objectivity, this type of
health technology assessment is nothing of the sort. It is designed
primarily to provide policymakers with a legitimizing rubric by
which they can mimic a few elements of the market and therefore
deploy a degree of fake economic rationality in justifying their
decisions. In this way, practitioners of HTA attempt to balance the
requirement to provide innovative health care technologies with
ham-fisted efforts at controlling the costs of those
Consider the quality of human life and lifespan. The use of
QALYs is pseudoscience. It is nothing more than a tool for central
planning that attempts to objectify what is inherently subjective.
The limited attempts to capture accurately the various "units of
healthcare benefit" mean that there is an inevitable gulf between
the theoretical underpinnings of QALYs and the actual behavior of
ordinary people. Moreover, the artificial prioritization of
so-called cost-based considerations by practitioners of health
technology assessment is invariably made at the expense of other
considerations. As Dr. Meir Pugatch and Francesca Ficai of the
Stockholm Network note, "Thus, a decision to prioritize a less
therapeutically effective medicine because of cost-based
considerations over an effective, but more expensive, medicine
could lead to some serious political, social and moral dilemmas."
Not only is this type of health technology assessment
methodologically flawed: It is incompatible with personal freedom
and contradicts the subjective choices of genuine economic agents.
When deployed at the national level through the power of a
government agency, it is inevitably subject to additional political
pressures. Indeed, in 2009, it is clear that national organizations
that conduct these assessments--such as the National Institute for
Health and Clinical Excellence in the United Kingdom or the
Institute for Quality and Efficiency in Health Care in Germany--are
in the business of rationing health care technologies so that they
mesh with the politically fixed budgetary allocations of the
Today, it is clear that the political economy of these
government bodies means that their structures, processes, and
pseudoscientific constructs have a significant and detrimental
impact on the practice of, and even the public discourse on, health
care. Far from reflecting scientific rationality and economics,
health technology assessments often reflect either politically
driven social judgments of the decision-makers in these agencies
or, worse, a thinly veiled attempt to accommodate whatever
political pressures happen to be momentarily dominant.
How Comparative Effectiveness Works in
According to the International Network of Agencies for Health
Technology Assessments (INAHTA), many industrialized
countries have bodies that are charged with health technology
assessments or comparative effectiveness studies. Despite this, the
evolution of these bodies and their responsibilities at the
national decision-making level has been far from uniform.
For example, some of these bodies have an advisory role. They
make reimbursements or pricing recommendations to a national or
regional governing body, as is the case in Denmark. Others have a
more explicit regulatory role. They are accountable to government
ministers and are responsible for listing and pricing medicines and
devices. This is the case in France, Germany, and the United
The United Kingdom. The experience of the United Kingdom
in making the difficult decisions about what kind of health care
technologies, devices, drugs, and medical treatments and procedures
should be favored in Britain's National Health Service has been
cited favorably by Senator Daschle.
The NHS was established in 1948. It is a single-payer health
care system, directly administered by the British government,
funded through taxation, and provided mainly by public-sector
institutions. Because the NHS is a fully nationalized entity, the
central government specifies the capital and current budgets of its
regional health authorities and determines the expenditure on drugs
by controlling the budgets given to each general practitioner.
Overall, NHS health care is rationed through long waiting lists
and, in some cases, omission of various treatments.
For the British government, the practice of HTA facilitates
rationing by delay. It is a tool that aims to ensure that expensive
new technologies are initially provided only in hospitals that have
the technical capacity to evaluate them. While the NHS Research and
Development Health Technology Assessment Programme is funded by the
Department of Health and, according to its criteria, researches the
costs, effectiveness, and impact of health technologies, the
Medicines and Healthcare Products Regulatory Agency (MHRA) ensures
that drugs and devices are safe.
In 1999, the government went a step further and set up the
National Institute of Health and Clinical Excellence (NICE). At
its heart is the Centre for Health Technology Evaluation that
issues formal guidance on the use of new and existing medicines
based on rigid and proscriptive "economic" and clinical formulas.
With the NHS obliged to adhere to NICE's pronouncements, criticism
of NICE has been ceaseless, particularly from various patient
NICE is a controversial body. It has tried repeatedly to stop
breast cancer patients from receiving the powerful breakthrough
drug Herceptin and patients with Alzheimer's disease from receiving
the drug Aricept. The criteria by which this agency makes its
decisions have been kept largely secret from the public. As is
inevitable with any nationalized health care system, life-extending
medicines such as those to treat renal cancers are refused on the
grounds of limited resources and the need to make decisions based
not on genuine market economics but on an artificial assessment of
the benefit that may be gained by the patient and society "as a
In 2001, NICE deliberately restricted state-insured sufferers of
multiple sclerosis from receiving the innovative medicine Beta
Interferon. Claiming that its relatively high price jeopardized the
efficacy of the NHS, patients with the more severe forms of the
disease were told that they would have to go on suffering in the
name of politically defined equity.
In more recent years, patients with painful and debilitating
forms of rheumatoid arthritis have been informed by NICE that in
many instances they will not be allowed to receive a sequential
range of medicines that have often been proved to be of significant
benefit. Instead, the institute decreed that "people will be
prevented from trying a second anti-TNF treatment if the first does
not work for their condition."
Similarly, in August 2008, patients with kidney cancer continued
to be denied effective treatments designed to prolong their lives,
often by months or even a few years. The calculations used by NICE
have been systematically disputed by clinical experts who are more
concerned with patient welfare than with vote-seeking, but the
institute has also come under fire for not involving doctors who
are active on the front line of medicine: "With Sutent for
instance, there was just one oncologist on the panel."
In January 2009, patients with osteoporosis also fell foul of
NICE. The institute declared that only a small minority of patients
with this debilitating disease would receive the medicine Protelos,
and even they would receive it only as an extreme last resort.
While clinicians and osteoporosis support groups have pointed out
that more than 70,000 hip fractures result in 13,000 premature
deaths in the U.K. each year and that these otherwise avoidable
episodes needlessly cost the NHS billions of pounds, not only are
patients being denied necessary treatments, but taxpayers' money is
Indeed, according to its annual reports and accounts, NICE is
now spending more money on communicating its decisions than would
be spent if it allowed patients access to many of the medicines it
is so busy denying them. The money that the institute now spends on
public relations campaigns "could have paid for 5,000 Alzheimer's
sufferers to get £2.50-a-day drugs for a year," according to
The Daily Mail.
Devoid of a market and the language of price, this top-down
system ironically ignores many of the societal costs associated
with failure to treat severe illness, such as illness-related
unemployment. Moreover, the fact that preventing access to more
costly medicines may save money in the short term overlooks the
costs for the future. If older medicines lead to more rapid
deterioration of a condition, the effect could be a more expensive
hospital or nursing home episode later.
Denmark. The Danish health care system is
completely state-funded, with public provision of hospital beds
representing more than 90 percent of thehospital sector. Under the
Healthcare Act, citizens are covered for all or part of
expenditures for treatment, including reimbursement for all
pharmaceutical products listed with the Danish Medicines Agency.
Therefore, there is no need for price regulation of drugs. With
central and municipal government having significant control of the
funding and provision of health care, the acquisition of new
technology is left initially to the five regions that run the
Denmark's national HTA system was explicitly established on the
basis of its making prioritized resource-allocation decisions.
Carried out by the unit known as the Danish Centre for Evaluation
and Health Technology Assessment (DACEHTA), it operates within the
framework of the National Board of Health (NBH), itself a part of
the Danish Ministry of Health. In reality, this means
that "[t]he Ministry keeps a close watch on it in order to
neutralize 'expensive' healthcare technologies, as their adoption
results in requests for extra funding from the regions."
France. In France, health care is a statutory
right enshrined in the Constitution of the Fifth Republic. Unlike
in Denmark or the United Kingdom, however, French health care is
financed mainly by social insurance and delivered by a mixture of
public and private providers. While two-thirds of French hospitals
are state-owned, one-third are private, with half of the latter
group being not-for-profit.
There have been various attempts in recent years to extend
government control of health care costs. In 1991, the French
government extended its Health Map system by which it controls the
capital construction of all hospitals as well as their budgets, the
purchase of medical equipment, the rates charged by private
hospitals, the number of pharmacies per head, and even the price of
In 2005, the government went a stage further with the
establishment of a centralized High Health Authority. While this
body has had only a limited impact--and France continues to enjoy a
comparatively higher diffusion rate for new technologies than is
found in many other countries in Europe--it is nevertheless
designed to stipulate the benefits of medicines and determine their
price-reimbursement levels. As such, it is set to raise the focus
on cost-containment and bring its decision-making under closer
Germany. As in France, health care in Germany is
financed primarily by social insurance and provided by a mixture of
public and private providers. While all services are contracted
instead of being provided directly by the government, more than 10
percent of Germans opt for full private medical insurance.
Providing a potent source of exit from the state, the regulated
private sector puts pressure on the government to ensure that the
sectoral differences in service do not become so wide that
ever-larger numbers of young, high-income consumers defect by going
private and delegitimizing a central pillar of the Bismarckian
While the pressure to maintain some semblance of parity with the
private sector meant that state spending rose dramatically for many
years after the introduction of a formal reference pricing system
in 1989, the strategic objective of the German Ministry of Health
has been to reduce supply, particularly through the use ofpublished
positive and negative lists concerning medicines and treatments.
Through these lists, pressure is applied to the statutory sick
funds to control costs.
It is in this context that health technology assessment has
played an ever-greater role in German health policy since the
1990s. In 1990, the Office of Technology Assessment at the German
Parliament (TAB) was established, and in 2004, the government set
up the Institute for Quality and Economic Efficiency in the
Healthcare Sector (IQWiG).
Tasked with the central goal of efficiency, IQWiG investigates
and stipulates which therapeutic and diagnostic services are
appropriate. Disseminating its pronouncements to
various self-governing bodies, its information is used concerning
the coverage of technologies in the benefits catalogue. With such
ventures being funded primarily by the German Ministry for Health
and Social Affairs, assessment bodies can refuse a hospital's claim
for reimbursement for the unauthorized use of new technology.
Lessons for American Policymakers
There is a pervasive European mythology: a widespread belief
that American health care is rooted in the free market. In reality,
much of American health care is a highly planned, regulated, and
government-funded system. Through major entitlement and welfare
programs such as Medicare and Medicaid, which contribute to rapidly
growing American health care costs, government takes a historically
higher proportion of gross domestic product than does even the
British NHS. Moreover, by virtue of the structure and financing of
private-sector health insurance, there is little consumer control
over health care dollars.
Nonetheless, the United States is not only a major consumer of
health care services, but also the world's largest producer of
medical technology. Investment in new medical technology is
comparatively high, as is its rate of diffusion: "This is
demonstrated by cross-national examinations of the comparative
availability of selected medical technologies such as radiation
therapy and open-heart surgery. Measured in units per million, the
United States experiences levels of availability up to three times
greater than in Canada and Germany."
During the presidential campaign, Barack Obama proposed an
Institute for Comparative Effectiveness that would make formal
recommendations on medical technologies, devices, and drugs. In
Congress, champions of comprehensive overhaul of U.S. health care
favor policies that would explicitly accelerate America's
trajectory downward toward a European-style medical
Fearing the impact of the rising costs of Medicare, Medicaid,
and the highly regulated arrangements of the private insurance
sector, many American legislators and other top policymakers are
becoming attracted to the idea of a body that would make top-down
pronouncements on the cost-effectiveness of new medical
technologies. The idea of a statutorily created agency charged with
system-wide cost containment and rationing of medical services and
technologies is becoming surprisingly fashionable in Washington
The implications of this trend are alarming for U.S. citizens,
particularly when one considers that the technology a society uses
reflects the wider and underlying incentive structures it adopts
for using it: "An incentive structure that encourages providers to
trade off the costs and benefits of health care gives providers
little incentive to use expensive technologies and thus researchers
will have little incentive to create it."
In the long term, a statist, centralized control of medical
technology offers little if any regulatory benefit. Through its own
logic, it not only stifles innovation, but also, in doing so, ends
up precluding those very inventions that could turn out to be of
immeasurable benefit to individuals and to society in general.
If comparative effectiveness and health technology assessment
especially are to be useful, they must be generated primarily by
the private sector on a competitive and non-coercive basis. In
avoiding the imposition of a uniformity of rules that comes with
government intervention, physicians and other medical professionals
would and should remain free to pick and choose from the best
practices and professional insights into the treatment of medical
conditions as they see fit (with, of course, the informed consent
of their patients).
It is only by returning health care to a genuinely
patient-centered and consumer-driven health care marketplace that
information, innovation, and best practice will permeate the
complex array of health care arrangements in both the public and
the private sectors. It is only through open competition and the
economic discipline of the free market that real progress and
productivity can be secured.
Therefore, in framing a policy on comparative effectiveness,
America's policymakers should be governed by four principles:
- They should reject the statutory creation of a board,
council, or institute that would centralize government control of
patient access to drugs, devices, medical technologies, treatments,
or procedures. This is especially the case if such an agency
were to have the power to override the considered judgment of
competing professional expertise, especially the professional
judgment of a patient's attending physician.
- Comparative effectiveness research and health technology
assessments should be undertaken primarily by the private
sector. While government can contribute to research efforts and
promote the widespread availability of the best information, it
must not exercise monopoly power over the conduct of research
itself or the distribution of information.
- Comparative effectiveness research should be
patient-centered and supportive of quality and value, not focused
simply on cost-containment. In this respect, it should foster
scientific advances, health information technology, and the
emerging science of personalized medicine.
- Comparative effectiveness research must move beyond
randomized clinical trials and embrace practical clinical
trials. It should include observational data, and its
methodologies should fully address issues such as the validity and
applicability of findings.
As is clear from the British experience and other international
examples, a comparative effectiveness strategy that relies on
central planning and coercion would not only be counterproductive
in the long run--because it would undermine the incentives for
medical innovation--but would also lead to the imposition of cost
constraints that would worsen patients' medical conditions and
damage the quality of their lives.
Helen Evans, Ph.D., is a citizen of
the United Kingdom. A registered general nurse, she is the Director
of Nurses for Reform and a Health Fellow with the Adam Smith
Institute of London, England.
a brief discussion of Daschle's proposed Federal Health Board, see
Senator Tom Daschle, with Scott S. Greenberger and Jeanne M.
Lambrew, Critical: What We Can Do About the Health Care
Crisis (New York: Thomas Dunne Books, 2008). See also Robert E.
Moffit, "How a Federal Health Board Will Cancel Private Coverage
and Care," Heritage Foundation WebMemo No. 2155, December 4,
2008, at http://www.heritage.org/research/healthcare/wm2155.cfm.
provision is included in Title IX of Subtitle B of the American
Recovery and Reinvestment Act of 2009. According to the report
language accompanying the House bill, "By knowing what works best
and presenting this information more broadly to patients and health
care professionals, those items, procedures, and interventions that
are most effective to prevent, control and treat health conditions
will be utilized, while those that are found to be less effective
and in some cases, more expensive, will no longer be
Stephen R. Brown, Scurvy: How a Surgeon, a
Mariner, and a Gentleman Solved the Greatest Medical Mystery of the
Age of Sail (New York: St. Martin's Press, 2003).
Ernest A. Codman, A Study in Hospital
Efficiency (Boston, Mass.: Privately printed, 1916).
A. Glover, "The Incidence of Tonsillectomy in School Children,"
Proceedings of the Royal Society of Medicine, Vol. XXXI
(1938), pp. 1219-1236.
Sanders, A. Coulter, K. McPherson, Variations in Hospital
Admission Rates: A Review of the Literature (London: King
Edward's Hospital Fund for London, 1989), p. 31.
Archie Cochrane, Effectiveness and
Efficiency: Random Reflections on Health Services (Leeds:
Nuffield Provincial Hospitals Trust, 1972).
E. Wennberg, A. G. Mulley, D. Hanley, et al., "An Assessment
of Prostatectomy for Benign Urinary Tract Obstruction: Geographic
Variations and the Evaluation of Medical Care Outcomes,"
JAMA, Vol. 259, No. 20 (1988), pp. 3027-3030.
Andrew Stevens, Ruairidh Milne, and Amanda
Burls, "Health Technology Assessment: History and Demand,"
Journal of Public Health Medicine, Vol. 25, No. 2 (1998), p.
Brian Micklethwait, "How and How Not to
Demonopolise Medicine," Political Notes No. 56, Libertarian
Alliance, London, 1991.
Meir P. Pugatch and Francesca Ficai, "A
Healthy Market? An Introduction to Health Technology Assessment,"
Stockholm Network, London, 2007, p. 5.
Helen Evans, Sixty Years On--Who Cares for
the NHS? (London: Institute of Economic Affairs, 2008), pp.
Pugatch and Ficai, "A Healthy Market? An
Introduction to Health Technology Assessment," p. 8.
"MS Research Urges End of NHS Bar on Drug,"
The Daily Telegraph, June 19, 2001.
See press release, "NICE Limits Options for
People with Rheumatoid Arthritis," Arthritis Cares, London, July
"Nasty Truth About NICE: It's the Body that
Rations NHS Drugs. But This Leading Cancer Specialist Says Its
Decisions Are Deeply Flawed," The Daily Mail, August 8,
"NICE Decision to Block Osteoporosis Drug
Access Was 'Irrational,'" The Daily Telegraph, January 20,
Meir P. Pugatch and Helen Davison, "A Healthy
Market? Health Assessment Technology in Context," Stockholm
Network, London, 2007, p. 9.
Brian Abel-Smith and Elias Mossialos, "Cost
Containment and Health Care Reform: A Study of the European Union,"
London School of Economics and Political Science Occasional
Paper in Health Policy No. 2, 1994, pp. 33-35.
Pugatch and Davison, "A Healthy Market?
Health Assessment Technology in Context," p. 10.
"American Democracy and Health Care,"
British Journal of Political Science, Vol. 27, No. 4
(October 1997), p. 573.
Pugatch and Davison, "A Healthy Market?
Health Assessment Technology in Context," p. 16.