Service of Cost vs. Benefit in Healthcare: Who Decides?

July 6th, 2015

Categories: Insurance, Medical, Medical Care, Medicine, Pharmaceutical

Photo rinehartclinic.org

Photo rinehartclinic.org

This New York Times article, “Cancer Doctors Offer Way to Compare Medicines, Including by Cost,” made significant—if terrifying–points in addition to how cost impacts what drugs a patient may get. Given their ineffectiveness, I wondered why those given as examples are prescribed in the first place.

If you or a loved one has a heart condition, don’t click away just yet: Reporter Andrew Pollack noted that cardiology societies are following in oncologists’ footsteps. And I wouldn’t be surprised if this trend soon affects patients with any and all conditions if it effectively cuts costs for insurers. 

Actor Robert Young playing Marcus Welby, MD

Actor Robert Young playing Marcus Welby, MD

Pollack wrote “Roche’s Avastin, when added to chemotherapy, had a net health benefit of 16 out of 130 possible points when used as an initial treatment for advanced lung cancer. Its monthly cost was $11,907.87, compared to $182.09 for the chemotherapy alone.

“Eli Lilly’s Alimta for that same use had a net health benefit of zero with a cost exceeding $9,000 a month compared to about $800 a month for the drugs it was compared to in the clinical trial.”

Later in the article Pollack spelled out the rating system: “Drugs for advanced cancer are given a score from 0 to 130. Up to 80 of the points are based on a drug’s effectiveness in prolonging lives, delaying the worsening of cancer or shrinking tumors. Then up to 20 points can be added or subtracted based on side effects. And up to 30 bonus points can be granted if the drug relieves cancer symptoms or allows a patient to go without treatment for a period of time.” 

Actor Hugh Laurie who plays Dr. House

Actor Hugh Laurie who plays Dr. House

Regardless of cost why would anyone prescribe a drug that benefits a patient from zero to 16 “points” out of 130?

Other news that was unsettling: “The release by the American Society of Clinical Oncology of what it calls its ‘value framework,’ is part of a change in thinking among doctors, who once largely chose drugs based on their medical attributes alone.” [The underline is mine.] Silly me: and I thought doctors still prescribe what they do according to how a drug helps a patient.

According to Pollack the average cost of cancer drugs runs $10,000/month and some as much as $30,000/month. This is information, Dr. Richard Schilsky said at a news conference, that some doctors don’t know nor do patients. Schilsky is chief medical officer of the American Society of Clinical Oncology. [Why is this significant? Even if you’ve been paying for health insurance for eons and have hardly used a cent until you need to, you can reach the ceiling when off goes the insurance spigot.]

Pollack wrote that this value framework considers the cost to the patient and the health system.  I assume “health system” translates to government supported Medicare and Medicaid plans. 

Ingrid Bergman playing Dr. Constance Petersen

Ingrid Bergman playing Dr. Constance Petersen

As a result, Pollack observed, doctors are now put in the role of “being stewards of societal resources.” He continued, “That is somewhat of a controversial role for doctors, since it might conflict with their duty to the patient in front of them. But the oncology society said it did not see those roles as being in conflict.”

Other points Pollack made include:

  • A rep for the Pharmaceutical Research and Manufacturers of America said the cost of drugs represents only 20 percent of treatment.
  • The cost of drugs is unrelated to how “novel it is or whether it prolonged life versus just shrinking tumors.”
  • In Britain, a drug is rated according to its “cost per extra year of life they provide adjusted by side effects and symptoms.”
  • Starting in June United Healthcare requires “oncologists to get prior approval from the insurance company for every cancer drug they administer. The company will then track what happens to patients and eventually provide information to doctors about how well each drug works.”

Summarizing the questions:

  • Why prescribe a drug that does little if anything to better a patient’s health or length of life?
  • Is a doctor who chooses a drug for a patient based solely on its medical attributes old fashioned and out of step and will he/she soon be forced out of work by insurance companies?
  • If a patient can scrape together the co-pay of a super expensive drug, can an insurance company refuse to pay its part? Then what?
  • Will United Healthcare only use its approval to track drug effectiveness, as Pollack suggests, or eventually will it control costs by refusing to pay?
  • Is the American Society of Clinical Oncology correct when it asserts that there is no conflict for doctors who are now made responsible for the country’s medical resources and their responsibility to their patients?
  • Unless people have unlimited incomes, most adults are aware of what they pay for food, beverages, clothing, shelter and only recently have they become aware of the cost of healthcare. Isn’t this a good thing?

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4 Responses to “Service of Cost vs. Benefit in Healthcare: Who Decides?”

  1. SEPTIMIUS Said:

    The first thing I thought of when I read this was the recent headline, “Aetna Buys Humana For $37 Billion.” That is a lot of money, and not a plug nickel of it goes to help anybody’s health. Worse, neither company was in the top three in health insurance in this country. Processing insurance claims is obviously a far more profitable business than helping people get well.

    The second thing I thought of was Greece. The Greeks are going through what happens to you when you live beyond your means for too long. Eventually you have to pay your bills or suffer the consequences. We may not like it, but we collectively cannot afford to have everybody get the same expensive medical care all the time. Some people are going to have to do without at least some of the time. As with the Greeks, our problem ultimately is how do we decide who has to die and who gets to stay alive?

    I think we should recognize that people are people; they are going to do what people do. The rich and powerful are always going to be treated better, get the best and most expensive doctors and medicines.

    Get rid of the insurance companies. That would save a fortune for sure. Convert the existing health delivery system to a military model, with military discipline. Everybody gets basic care delivered efficiently and cost effectively. And if you want something special, like a doctor to hold your hand, a hospital room with a view of the East River, or a $10,000 a month medicine, you can have it as long as you pay for it yourself.

  2. Jeanne Byington Said:

    SEPTIMIUS,

    Health insurance once worked. Did we lose the formula because medicine and hospital care didn’t cost what it now does? I worked for a small company and it had an excellent program that was part of the employment package. My husband’s large company also had a very good health insurance policy. I agree that greedy insurance companies may be part of the problem these days, but wouldn’t control of the costs of healthcare–and the profits of these companies–be a more viable solution than killing the protection insurance is supposed to offer?

    If you believe as I do what Bernie Sanders says there won’t be the numbers of people needed to warrant medical research. Sanders claims that the top one-tenth of one percent owns as much wealth as the bottom 90 percent and that 99 percent of all new income generated today goes to the top one percent.

    Extrapolating this, only the top one tenth of one percent could afford lifesaving drugs and care.

    As a former Air Force wife the military medical care I received was fine–I was in my early 20s and didn’t need much of it. I’ll never forget the vaccination some airman gave me improperly that caused pain for weeks–I couldn’t raise my arm above my eye for that lenght of time either. But it didn’t kill me.

    There are other ways to control costs and we are doing some of these ourselves. It may not result in a system where a family physician comes to a home on a Sunday to diagnose appendicitis—as one did and saved my father’s life. Those days are over. But while I haven’t used the medical services that have cropped up around the city where people drop in round the clock I hear that they are great. They take pressure off hospitals. It took me too many months to get up the nerve to let a pharmacist give me an injection but I’m here to tell the story even though the pharmacist admitted that he’d had no training–nor is anyone taught this in Pharmacy school.

  3. Lucrezia Said:

    This conversation is way over my head. One thing is clear: Unless insurance companies are brought to heel, unless $0.10 pills are not costing a patient up to $400.00, matters will only get worse.

    I’m not joking about that pill. Check it out!

  4. Jeanne Byington Said:

    Lucrezia,

    This is a BIG part of the problem—good point. The cost of meds given in a hospital is inflated I’ve read and imagine what military hospitals are charged!

    When I broke my foot the orthopedist’s nurse asked me if I’d ever broken my foot before and since I hadn’t, and I’d never been given a boot–that you get these days instead of a cast–she said it would be covered by insurance. I asked how much the boot cost. It was well into the $hundreds. If you look the boot up on line, you can get a new one for under $100. [Trouble is, if you break something you need the boot right away so as not to walk on a broken bone and make things worse, so you’re caught.] And the boot isn’t fitted to your foot in any special way. It comes with velcro and you get your size.

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