Who decides whether a patient gets the costly treatment?

[Alex3]

Hi there,

Last year my partner went in for a routine operation but ended up in ICU due to multiple organ failure. Fortunately, in his case, the ICU consultant had recently been involved in a new drug and gave it to my partner. Needless to say, he survived.

In the event his cancer returns, he has been verbally informed he will receive a drug to shrink his tumour, which costs about 20k p.a.

I'm thinking of doing a presentation on this for my nursing course, so would appreciate any advice, thoughts and opinions about the following:

1. How do trusts decide who gets the 'expensive' treatment.
   
2. What is the process?
   
3. Who are the decision makers?
   
4. What are the factors that influence these decisions?
   
5. Does geographical location play a part in getting these treatments?
   
6. How would you deal with patients who have not been successful in getting their preferred treatment? Any stories?

Thanks as always!

[SFCardiacRN]

Ultimately, the insurance carrier decides what treatments are covered.

[fergus51]

I work NICU and insurance has nothing to do with it since we have to treat everyone who needs it. If the doc orders it and the parents agree, the baby gets it.

[grannynurse FNP student]

Hi there,

Last year my partner went in for a routine operation but ended up in ICU due to multiple organ failure. Fortunately, in his case, the ICU consultant had recently been involved in a new drug and gave it to my partner. Needless to say, he survived.

In the event his cancer returns, he has been verbally informed he will receive a drug to shrink his tumour, which costs about 20k p.a.

I'm thinking of doing a presentation on this for my nursing course, so would appreciate any advice, thoughts and opinions about the following:

1. How do trusts decide who gets the 'expensive' treatment.
   
2. What is the process?
   
3. Who are the decision makers?
   
4. What are the factors that influence these decisions?
   
5. Does geographical location play a part in getting these treatments?
   
6. How would you deal with patients who have not been successful in getting their preferred treatment? Any stories?

Thanks as always!

Gosh, well.

Expensive treatment

Depends on your type of health insurance coverage and the limits of your policy. If you can afford the extra monies, you can generally buy it. If you are on Medicare/Medicaid, that is an entirely different matter, depending on your state's own guidelines and appeals process for denials. No insurance, of any kind, you get emergency treatment but little else.

Woops I just saw the word 'trusts'. We don't have them here in the United States. Guess that ends my answer.

Grannynurse:balloons:

[ruthn]

Are you in the UK? (You said 'trusts').

If so, then I think it's all regulated by NICE. They will assess the clinical evidence for the intervention, and then recommend whether/who it should be offered to. Trusts will generally make their decisions based on this guidance, although they're allowed to make exceptions. That was the whole issue with herceptin recently in the news. NICE was created in order to standardise treatment across the country, in the government consultation document 'a first class service' (1998ish?).

[MultipurposeRN]

No insurance, of any kind, you get emergency treatment but little else.

We get many self pay patients in my hospital. We have quite a few coming in for chemotherapy every month or so. So far, we've never turned anyone down for lack of money, though the financial counselors will discuss payment options and we have some resources to see if they quality for assistance.