Is it Worth It?

Spending to death: How much is living worth?
Costly new cancer drugs and heart pumps bring wrenching choices
The Associated Press

Updated: 9:46 a.m. ET Aug 13, 2006

Dying of lung cancer, Carolyn Hobbs tried a new biotechnology drug that produced an unanticipated side effect: acute sticker shock.

She was waiting for her second treatment in a hospital near Denver less than two years ago, when someone from the business office marched in to warn that her share would cost more than $18,000, since the drug wasn’t insured for her type of cancer.

How to decide?

In her six decades, she had shared in a long marriage, raised three children, worked in a nursing home, painted as a hobby — and wasn’t ready to leave it all behind. But she was also a careful spender who sometimes returned new clothes to the store, deciding she didn’t really need them.

Maybe this new drug, Erbitux, could extend her life by a small fraction, but she wouldn’t be cured. “She was just very frugal, and she said it wasn’t worth it,” her husband Larry remembers.

So she refused the treatment.

More patients are confronting this wrenching decision, as the latest generation of pricier cancer drugs and heart implants stretches out the final months of advanced disease. Is the chance for several more months of life — maybe a year or more with luck — precious enough to spend a small fortune? This dilemma is also challenging governments, employers and insurers, who all help finance America’s longer life spans and innovative technologies.

Care or research?
Extraordinary care for dying patients can make for inspiring medicine, but its extraordinary costs make it an increasingly debated choice to promote public health. Many economists, doctors, and ethicists say this care too often buys too little for too much — and that its expanding share of medical resources might better pay for screening and treating diseases in earlier stages.

Already, up to 30 percent of annual payments by federal Medicare insurance go to the 5 percent of members in their last year of life, research shows.

“People still have an underlying belief that there’s an infinite amount of resources that can be invested in health care,” says Dr. Harlan Krumholz, a Yale University heart specialist who studies quality of care. “But I think we’re coming to a realization that we’re going to need to confront these issues explicitly.”

Maybe so, but any retreat from last-resort care still raises objections from many patients, doctors and medical companies. They denounce “rationing” of care and defend expensive treatments for the dying as a moral imperative.

A costly chance at life
Within the last decade, an array of expensive new treatments has given some patients their first real fighting chance against common diseases once routinely called “terminal.” These treatments include:
# Cancer drugs manufactured in living cells, instead of beakers. These biotech drugs target just diseased tissue, unlike chemotherapy. Thanks to these drugs, some late-stage colon and blood cancers are no longer hopeless.
# Implants that help the heart pump blood. These devices — the most common is the left-ventricular assist — are heir to decades of research in artificial heart technology. They provide an option for some patients with failing hearts.

Some of these therapies, like the biotech drug Gleevec for leukemia or implanted defibrillators for some heart problems, work wonders in many patients. The trouble with many treatments, though, is that average patients gain only several more months of life, studies have found. A lucky few may survive for years, so many seek treatment in the hope of beating the odds.

“Very few people, when told of a potential life-saving intervention, will not be willing to listen. So the question is now not whether it will help or not, but who pays?” says Dr. A. Mark Fendrick, at the University of Michigan.

Whoever pays, costs are up. This care costs several times more than the older treatments it supplements or replaces. A last-resort cancer drug can cost up to $50,000 a year — if patients survive that long — with insurance typically picking up at least two-thirds. A mechanical heart pump can cost more than $200,000, with hospital care.

Death as a personal choice
Reports of these breakthroughs, which often fail to mention the price, may have intensified the distinctly American tendency to view death almost as a personal choice, suggest doctors and ethicists.

“I have two small children, and dying right now is not an option,” colon cancer patient Rebecca Dague, of Medina, Ohio, said recently.

Faced with such a disease, more than a third of Americans now would want “everything possible” done to save their lives, up from just over a fifth in 1990, according to a poll by the Pew Research Center for the People and the Press.

For many on the brink of death, the choice of desperate measures is hardly a choice at all.

“It’s better to pay the money than sleeping with the worms,” said Jake Rogers, 62, of Chicago, of his implanted left-ventricular assist device. His doctors implanted a second one in June, when his first wore out after 15 months.

From their first day of medical school, doctors are trained to do their utmost for patients like Rogers. “I think probably there’s more tolerance for high cost at the end of life, when all the options have been exhausted,” says cost analyst Milton Weinstein, at the Harvard School of Public Health. “I think there’s a moral force that causes us to want to do anything we can, irrespective of the cost.”

Huge insurance payouts
While doctors advocate for the interest of dying patients, they may also be subtly swayed by earning their livings partly from providing this care. And many patients don’t fret, because they are insulated from huge payouts by insurance.

Robert Graham, 73, of East Brandywine, Pa., chuckled when he heard the high price — up to $250,000 — of heart pumps like the one implanted in him last November. It was covered by insurance.

“I got to live a long time to be worth that!” he said. Yet the average patient in the best medical test so far lived less than nine more months.

Federal safety regulators do not regulate the price of end-of-life treatments. They evaluate only if drugs or devices work, not how well they work for their prices.

Medicare, which insures about 80 percent of dying Americans, makes no acknowledged evaluation of cost in deciding what to cover. It is not allowed to negotiate for lower drug prices. Its coverage umbrella sets a standard for private insurers.

Under such pressures, the $1.9 trillion spent on U.S. health care in 2004 will balloon to $4 trillion by 2015, federal forecasters project. In that year, health spending, which claimed 16 percent of the economy in 2004, would consume 20 percent and cost the average American $12,400.

Some believe the country can afford to spend even more — and that it’s worth it. Others fear a crash, with insurance perhaps turning into a luxury item. Nearly everyone, though, agrees there’s an upper limit somewhere on the horizon.

“So far, we’ve given everything to everybody,” says economist Lester Thurow of the Massachusetts Institute of Technology. “We haven’t made the tough choices yet.”

Hard choices
Yet choices are being made every day, case by case.

Some insurers refuse to cover a treatment. Doctors send patients home to die, sometimes out of mercy. Some patients say enough is enough.

Dr. David Johnson, at Nashville’s Vanderbilt-Ingram Cancer Center in Tennessee, pitched Erbitux to his brother-in-law, a 57-year-old married truck driver with advanced colon cancer. However, the drug has barely been proven to extend average survival at all.

The doctor remembers his brother-in-law refusing and saying: “Are you stupid? I’m not giving up my limited resources.”

The drug’s marketer, Bristol-Myers Squibb, did not reply to repeated requests for comment.

Insurance's subtle controls
Employers and insurers are discreetly controlling costs through premiums, deductibles, co-payments, caps, and even outright exclusions. “Benefit costs would go through the roof if there were no considerations given to the costs,” says Karen Ignagni, president of the trade group America’s Health Insurance Plans.

Despite official denials, the federal Medicare program makes subtle cost evaluations, says Dr. William Maisel, a Boston heart specialist who chairs a federal committee on cardiac devices. “I think they are concerned about people using the term ‘rationing’ or ‘withholding therapies,”’ says Maisel, at Beth Israel Deaconess Medical Center.

One way to control costs, without saying “no,” is to keep reimbursements low. For example, Medicare’s $140,000 reimbursement last year for heart pumps is widely acknowledged as below-market.

“We can’t say, ‘No,’ explicitly. We say, ‘Yes, but,”’ explains Peter Neumann, who runs a Tufts University center on medical cost-effectiveness in Boston.

Yes, but start with a cheaper drug, get prior authorization, or make a bigger co-payment.

Or, for the 45 million uninsured: Yes, but go to the emergency room and rely on charity for extended care. The nonprofit Patient Advocate Foundation reports that nearly half of its cases or requests for help involved co-payments last year, up from just 5 percent in 2002.

“If you’ve got a thick wallet or a full purse, you can get any care you want. If you don’t, there’s rationing for you,” says former U.S. Health Secretary Joseph Califano, who later dealt with escalating health costs as a board member at Chrysler Corp.

“We’re going to have to think very hard about how to provide some of these truly exotic treatments,” he adds.

Calculated decisions
Many now press for more systematic thinking about cost controls applied by insurers, hospitals, and policy makers. They say medical guidelines should more strongly steer older, sicker patients — and other inappropriate candidates — away from the most expensive treatments.

Cost-effectiveness analyses should be applied, they say. One common approach calculates the cost of a treatment for each year of life it saves. Many health economists view $50,000-to-$100,000 as a reasonable upper limit for what public and private insurers should pay.

Such calculations include adjustments for lost quality of life. For example, a heart pump is clearly less valuable if it puts a patient in the hospital for three of his last five months with a miserable infection.

Heart pumps were first used as a temporary bridge to a heart transplant and only approved as regular implants in 2003. About 1,000 were implanted last year, but the ultimate annual market is estimated in the tens of thousands. Yet an analysis last year put their cost-effectiveness at between $500,000 and $1.4 million per year.

Even one of their pioneers, Dr. Eric Rose at Columbia University, concedes that would make their value “more than challengeable,” but he expects improvements.

“It’s hard for me to justify in a society that’s falling short in basic health care,” adds heart doctor Steven Nissen, at the Cleveland Clinic, a federal adviser who voted against expanding use of heart pumps beyond patients waiting for a transplant.

Dr. Barry Straube, who heads the Medicare unit that decides what to cover, believes “it would be helpful in setting priorities when we have limited budgets to look at cost-effectiveness.”

$20,000 buys five months of life
Take also the example of the new biotech drug Avastin, which treats colon cancer for about $4,400 a month. Effectiveness? It is proven to extend average life by up to five months. In a survey this year, only one-fourth of 139 cancer doctors felt that represents “good value.”

Genentech, which makes Avastin, believes its drug prices provide reasonable value to patients and powerful financial motivation in-house to improve treatments for a terrible disease, says Walter Moore, a company vice president. However, he says Genentech may impose its own lifetime cap on a patient’s charges for Avastin.

For now, many hospitals partner with drug companies to treat dying patients for free, especially in the early stages of testing. Dr. Roy Herbst, at the M.D. Anderson Cancer Center in Houston, says the price of biotech drugs has forced the subject of cost into his discussions with colleagues for the first time.

“If we lost $30 million a year on Avastin, those are things that couldn’t go into research and support programs,” he says.

Others, too, question the current priorities of U.S. medicine.

“We’ve prioritized end-of-life care as more important than preventive care or chronic care,” says Dr. John Santa, medical director for the Center for Evidence-based Policy in Portland, Ore.

Doctors, says University of Pennsylvania heart surgeon Dr. Michael Acker, should keep away from “high-tech, expensive technology just to postpone the inevitable.”

“In the highest-benefit patient, you don’t get that much benefit, and it costs a lot,” adds Alan Garber, a Stanford University doctor and economist who chairs a Medicare coverage advisory panel and questions the value of both heart pumps and Erbitux.

Carolyn Hobbs’ husband disagrees, at least in her case.

Though she initially refused Erbitux because of cost, she ultimately arranged to get that drug and three other biotech drugs for free, with help from her doctor, hospital, Medicare and the drug industry. Her husband says she managed to keep a reasonable quality of life, even through most of her final months.

She died in November. To this day, her husband isn’t quite sure how much was spent.
© 2006 The Associated Press. All rights reserved. This material may not be published, broadcast, rewritten or redistributed.

URL: http://www.msnbc.msn.com/id/14235415/

Social Justice- The Last Post of the Day

I am a regular at studentdoctor.net. Today, I spent a great deal of time at that site, as well as working on this blog, because I am off of school due to a hurricane that never arrived, and I don't have a whole lot of work to do before Labor Day Weekend. Anyway, during what has become a rather lengthy debate on that site regarding Walmart, health insurance, government oversight, and walk in clinics, I was accused of not leaving room for social justice in a capitalist system. This got me wondering, what is socal justice?

I think that I will break social justice down into two categories, though I am not necessarily a big believer in the concept. These are two definitions that are used: 1. Social Justice is an obligation given to society to provide the greatest good to the most people within the society. 2. Social Justice is defined as a right or deserved stake or interest in something given to a person or group through some sort of ethereal decree or concensus of the members of that group. As I believe that definition two is nothing but the political ravings of special interests, I will focus on definition one.

In order to provide the greatest good, one must first define good. Is there an objective or a subjective definition of this? Is good defined by an amount of money or security, or rather by a subjective definition of happiness. Anyone who hasn't been living in a box knows that most people today (even the poor) in most of the developed world have more than just the basic necessities of life. The residents of even the poorest areas in the United States have electricity, food, and shelter (This being with the exception of those that choose not to take advantage of the shelters provided to homeless people in almost every metropolitan areas by both public and private groups). Some may argue about the food, but I haven't seen any massive death by starvation in the U.S. Nobody is living in mud huts, worrying about hunting food, and urinating in the bushes in the US (except for those that do this by choice and find it fun). What amount of money or security would then be correct? In 100 years, as technology advances, will we then be unjust for having people living in the same conditions they do now, or is social justice some abstract concept of everyone having access to every innovation?

So this brings us back to social justice. Good could probaby be defined by most moral (non type-2) proponents of social justice as providing the highest possible quality of life for the most people in society, with quality being defined as a mixture of subjective happiness and objective material security and comfort. At the root of American Social Justice, Thomas Jefferson wrote into the Declaration of Independence the idea of "Life, Liberty, and the PURSUIT of Happiness," an idea that he took from Lockean political thought, "Life, Liberty, and Property." We created a Constitution, outlining what the roles of the government were in the provision of "social justice."

So one might ask how social justice can be brought about, and more importantly, what does any of this have to do with healthcare? The socialists will cry, the communists will curse, and the fascists will scream, but consistently, the highest quality of life has been given to the most people by Capitalism. This is highly visible both in the U.S. and abroad.

I live in Miami. Here, there is a large population of Cuban exiles who fled the Communist Castro regime. I often hear people quoting statistics out of Cuba regarding their healthcare system, putting it up as a beacon of socialist efficiency. I get a far different story from the Cubans I talk to, who tell me stories of hospitals with no sheets and a far different system that is available for the average worker than the toursits or government officials. The healthcare shortages, coupled with statistical falsehoods, are the norm in all areas of communist life, in stark contrast to most goods and services in more capitalist markets.

In the US, we constantly scream about education and healthcare. They are falling apart. They are inefficient. They are expensive. These happen to be the SAME two services that are most regulated by the government. As they fail more, we give the government more power to regulate them. Nobody ever seems to think that the government intervention in the market may be causing the problem (I will expand on this charge in later posts). The system is full of shortages, regulation, and inefficiency. Even the history of American Health Insurance, the private side of healthcare in the US, goes back to government wage regulations during the great depression.

So by the above definitions, capitalism provides the greatest social justice. As I alluded to in my previous post about Coke, capitalism seems to bring a service to the most people for the cheapest price. Therefore, the greatest good is supplied by Capitalism (Capitalism doesn't necessarily=conservativism, so I don't want rants about corporate welfare. That is not capitalism). The greatest good is supplied to society by the providing the greatest good to individuals. Capitalism is the ONLY economic system that doesn't put the power of regulation in a small number of beauracrats. Because the market regulates the system, every individual is a consumer, and everyone is a regulator. Thus, the greatest good is done for the most people as everyone has a say in the market. Any intervention by the government distorts the market in favor of one group over another, creating false market incentives. This creates LESS quality of life for everyone in favor of a minority.

Thus, leaving definition #2 behind (Unless you happen to belong to a special interest), capitalism does the greatest good for the most people. Capitalism provides the most goods, the cheapest quality, the most security, and greatest access to necessities by all members of society. In our society, it is the most heavily regulated industries that are available only to the wealthy. So a vote for capitalism is a vote for social justice. For those that see healthcare as a social good, that should be only more of a reason to let the market provide it. That would be the quickest way to make progress towards "social justice."

The Cash Incentive

Have you ever really wanted a Coke? It's a hot day, you didn't sleep well the night before, and you're looking for a little caffeine. What do you do? I personally go to my local grocery store, buy a 2-liter for $0.80, and go home and enjoy. If I really want it badly, I'll pay a little more for a little less (paying for convenience), buy the 20 ounce out of that little fridge in the front of the store and have my desired beverage within minutes of my initial thirst.

The above is really an amazing process. Having visited the Coke Museam in Atlanta, GA as a child, I recall how fascinating everything was in the manufacture and distribution that made all of this possible. Even now, I can have Coke in almost any convenience store, vending machine, or restaurant in the country.

So, why is it that Coke is so omnipresent in my life, but healthcare is so hard to come by? Coke effectively supplies billions of people across the globe with a variety of products and with extreme accuracy. Healthcare, on the other hand, requires waiting, huge expenses, and a variety of other inconveniences that I don't deal with when I want a Coke. For those who think that Coke and Healthcare don't correlate, the above scenario plays out with all sorts of complex undertakings all over the globe, including cars, computers, building supplies, and even the manufacture of the machines used in the execution of healthcare.

Why is Coke so efficient? The answer, the cash incentive. Coke has to compete with Pepsi and hundreds of store brands around the country. If Coke were hard to come by, people would eventually just start purchasing other brands. If Coke didn't taste good, people would start buying other brands. Thus, in order to compete and make money, Coke has to be efficient and tasty. Increased efficiency and better service provide Coke, its stockholders, and its executives with a direct financial incentive to do a good job. The industry is relatively unregulated compared to other industries, and Coke operates with minimal intervention in its quest to provide the consumer with a tasty and efficient product, which correlates to wealthy owners of Coke.

So I can take in huge amounts of Coke for almost no money, but I cannot get treatment for simple medical problems. Why? There is a lack of cash incentive.

Medicine is funded almost entirely by the federal government, the state government, and a huge number of well regulated insurers. It operates under constant threat by a legal system that sets an arbitrary standard of care and spends billions of dollars chasing down those that don't meet that standard. Doctors, no matter how responsible, are still motivated by money like anyone else. As a doctor, the current system pays you to spend less time with patients (By not compensating for more time). Inefficiency is the norm, as every small office visit becomes a nightmare of paperwork and red tape. Worst of all, almost every decision is now made not to provide the best care at the lowest cost, but to prevent litigation. Preventing litigation is the medical profit motive, as the government money will be there for more and more tests, but the doctor pays if he/she is sued. Thus, excessive testing and slow inefficient care are the NORM.

Every new and profitable venture in medicine that actually provides basic care for a low price or excellent care for a high price is attacked constantly in the press. Think about the Walmart urgent care clinics that are the subject of such controversy, allowing people access to basic treatment with no waits and efficient resource utilization. Think about the concierge clinics that were berated for so long until they were repeatedly shown to have BETTER outcomes. If Coke took such a barrage, I doubt that I could have it whenever I wanted.

Worst of all, think about the poor, the usual trump card of the anti-capitalist medical proponents. Almost every poor person in the US has access to Coke. If you have ever spent any time around public housing, you would see that many of these people have access to TVs, Stereos, Cars, and many things that are more expensive than Coke. Why can't they afford Medical Care?

The answer is simple. Right now, there are no Walmarts or Cokes of Medical Care. It is all high priced. It is all highly regulated. Many companies have managed to make a LOT of money in high volume, low margin services to the poor. Usually, this is to the mutual benefit of both. In medicine, we let the government do it, and the number of underserved keep growing. Of course, the government has no profit margin.

Medicine and Economics

This will be my first rant (uh post) on this blog. I am hoping that we can delve deeper into the taboo subject of money and healthcare in a public forum. I am generally of the opinion that there are laws under which the world operates. Just as there are laws of physics, chemistry, mathematics, and nature, there are also laws of economics. I believe that in the healthcare industry (An industry that constantly deals with life and death) that these basic laws are often overlooked or ignored completely. This has brought about a bizzare system, wrought with shortages, that is progressively offering worse care at a rising price. Though this is handled differently in different countries, this is a definite trend all over the world, leading to excessive waiting and limited healthcare choice in countries such as Canada and the UK, while causing huge cost bloating and limited healthcare access in the United States.

After this post, I intend to post possible solutions. My e-mail is available publicly, and any well written dissenting opinions may be published as well. I am also hoping for a good debate in my replies section. I hope to include individuals with diverse backgrounds, with experiences outside of the medical system as well. If you work in Medicine, Law, Business, Economics, Anthropology, or any other discipline that uses or studies money or healthcare, your opinions are welcome here.