Saturday, July 18, 2009

Health Care: How Much Is Too Much To Save A Life?

Here's a question...
"You have advanced kidney cancer. It will kill you, probably in the next year or two. A drug called Sutent slows the spread of the cancer and may give you an extra six months, but at a cost of $54,000. Is a few more months worth that much?

If you can afford it, you probably would pay that much, or more, to live longer, even if your quality of life wasn’t going to be good. But suppose it’s not you with the cancer but a stranger covered by your health-insurance fund. If the insurer provides this man — and everyone else like him — with Sutent, your premiums will increase. Do you still think the drug is a good value? Suppose the treatment cost a million dollars. Would it be worth it then? Ten million? Is there any limit to how much you would want your insurer to pay for a drug that adds six months to someone’s life?

If there is any point at which you say, “No, an extra six months isn’t worth that much,” then you think that health care should be rationed."
That's the beginning of an article by Peter Singer from the New York Times last week:
Why We Must Ration Health Care

How can you not come away from it thinking healthcare needs to be rationed? (Not hard to see it's already being rationed.)

The dilemma ... how much do you limit care? To whom? Should an 85-year-old receive the same benefits as a 14-year old?

What if the question wasn't saving a life but curing disability? What cost would we bear, if we had the technology, to return a quadriplegic to an active and independent life?

Certainly, something needs to change about how much we're spending:

Click to enlarge.

And how much it's projected we'll be spending:

Click to enlarge.

Related posts: "High Quality, Equitable Care For Every American, That Should Be Our Goal." -Maggie Mahar
Source for graphs: White House Council Of Economic Advisers, The Economic Case For Health Care Reform, Executive Summary, June 2009


Clamence said...

I like to think the goal of the health care system is to improve the quality of life as well as reduce the mortality of as many people as possible.

The debate is not about whether or not someones life is worth $54,000. Rather, it is about whether or not $54,000 can be better used to save more lives, or increase more individuals quality of life.

With such a big number like $54,000 for six months of life of one individual, the answer is easy no given the current condition of our health care system. $54,000 of cod liver oil would provide roughly 20 individuals with 3 grams a day of omega-3 fatty acids for 10 years. At least one of these individuals would see at least 6 more months of life from just the reduction in cardiac events.

No drug costs $54,000 to produce and make a comfortable profit off of, and if the technology really is that expensive, the treatment simply isn't ready and needs to be engineered in a more cost effective manner.

The rhetoric that drug research is expensive is illusory. Current drug research is "expensive" because it is profitable to spend millions on research and sell a product for $54,000 for 6 months of treatment. If it was not possible to sell the drug such exorbitant rates, drug companies would simply develop more affordable treatments.

The same can be said for other medical technologies. An MRI does not cost $1000, once the cost of the machine is recouped all that's needed is the power and technician salary. $1000 * 20/day * 365 ~ $7.3 million dollars, anyone know a place where they get replace the MRI machine each year?

I had ACL reconstruction surgery two years ago, and paid $1300 on top of the $2000 my insurance company covered for: a pair of crutches, knee brace and a machine that continuously flexed and extended my knee. All of these items could have been built for no more than $500 with a healthy profit.

The problem is with how we allocate resources within the health care system. When companies involved in providing health care make tremendous profits, it reduces the quality of care that can be provided and accounts for our spending as a share of gdp.

Bix said...

"The rhetoric that drug research is expensive is illusory. ..."

This is a really good point. I've thought about this - how are these prices determined? The article says:

"Pharmaceutical manufacturers often charge much more for drugs in the United States than they charge for the same drugs in Britain, where they know that a higher price would put the drug outside the cost-effectiveness limits set by NICE (National Institute for Health and Clinical Excellence)."

If it's true that prices are set by what a market can bear, then our market must be able to bear these prices, people must be paying them, able to pay them. At least until now.

Perovskia said...

In Canada we have the option (sometimes) of choosing a generic make of the drug, vs. the "real" thing. Why can't they just make an affordable "real thing"? (just like you said). Why both? I don't understand that.

Anrosh said...

The worst crime that one can commit in the united states of america is falling ill/sick in body.

the insurance companies have reduced health care to a financial model.

and the banks have added pharmaceutical companies as one of the most profitable companies for their business for underwriting.

and physicians drumms up the business if they find one with a good health insurance !

and if one does not have an insurance - being put in jail is better than being penalised .

for a developed country not to be able to take care of their citizens is a pity

Dr. Mel said...

You're right, it is already rationed, and not just for direct profit--sometimes it's a more circuitous route to a profit. For instance, I knew someone dying of cancer who was turned down as a patient at Fox Chase, not b/c she couldn't pay for the care, but b/c her likely death would worsen their success statistics, so they couldn't compete as well w/ other cancer centers.

Personally--and this is *only* personal--I don't think we have the right to judge whose life is "worth" being saved, whether it's a question of age, social class, disability, certain mortality, or any other reason. Who are we to say who's "worth it"?

Who would any of you choose, and how much would you be willing to pay? It reminds me of "Sophie's Choice."

Jennywenny said...

NPR recently discussed paliative care (sp?) where people were aggressively treated for diseases when it was clear they werent going to survive. So for a lot of money and suffering, they were able to spend a few more weeks/month in the hospital, instead of having a restful hospice experience where they could have a serene end of life experience.

Improving this area of healthcare would save billions of dollars which would be better spent on treating people who need it. I realise this is a very difficult area but it needs to be addressed.

Anrosh said...
I'm the former insurance industry insider now speaking out about how big for-profit insurers have hijacked our health care system and turned it into a giant ATM for Wall Street investors ....

Thanks to charakan, a physician from India who has an interesting take on socio-political and economic things...that's how i came on this link

ElDoubleVee said...

Would I pay 54K for another 6 months? If it was just me involved in the decision I would say sure. Can’t take it with you, what. But if a wife and/or family is involved is stripping them of 54K the correct thing to do. I don’t have 54K lying around. I have a house to second mortgage but who pays off the mortgage when I, the main breadwinner, die. Doesn’t seem like the right thing to do. I would rather die quickly, which is bad enough, without further burdening my wife. I would probably try to buy a bunch of heroin and go out addicted and zonked but pain free.

Dr. Mel said...

I just (personally) think it's a slippery slope (morally, ethically, spiritually) when you get into the territory of other people deciding who is "worth" saving and who is not, most particularly when the grounds are financial and it's questions of age, intelligence, gender, race, etc. Bix poses this question: "But suppose it’s not you with the cancer but a stranger covered by your health-insurance fund." It's a good question, but every stranger is also a "me/I," just not one in our personal orbit.
And the notion of rationing health care ironically also begs the question of assisted suicide, still illegal here.

y2fizzy said...

I work in a field that is tangentially related to the pharmaceutical industry, and I think it is important to speak up about just how difficult it is to develop a new drug. The current estimation is that bringing a new drug to market takes $1 billion. That’s a lot of money in its own right. What that figure fails to convey is the extreme amount of time and money that is invested in drugs that will never see the light of day.

Our understanding of drugs and how they work in the human is painfully limited – we just aren’t capable right now of predicting exactly how to construct a drug so that it specifically targets the right thing (if we’ve even got the right target) and misses the thousands of other things that could cause dangerous side effects. The best way we have to ensure that drugs do the right thing and only the right thing is through rigorous testing.

This starts with Hundreds of Thousands of molecules. Assuming we don’t have to build them from scratch (also a very difficult and expensive process), we then screen them against possible disease targets to see if anything works. Less than 1% of them will actually hit something productive. These winners get multiplied by chemists who try to optimize their effects, then get pared down again through testing in cells and eventually animals, until a suitable candidate is identified to treat a disease. Suitable means that this candidate (to the best of our knowledge, which is still woefully inadequate): 1. hits the expected target, 2. produces a promising clinical effect, 3. is unlikely to produce intolerable side-effects, and 4. is practical to administer to a human.

At this point the drug candidates are ready to enter human testing. They will run a gauntlet of challenges against placebos and existing drugs to make sure they worthwhile. Of the 3,500 or so new drugs that enter human trials every year, how many of them will (about eight years later) eventually be approved for sale by the FDA?

About 20.

It’s true that an actual MRI costs very little, once the machine is built, but there are many other hidden costs: a physicist had to understand the molecular principles, a biologist had to translate those principles into a medical interpretation and use, an engineer had to build a machine that could get the information from an actual human body, a computer scientist had to program the software that could interpret the data into an image, and a doctor had to translate that image into a meaningful diagnosis.

A huge amount of time and expert knowledge goes into the development of any new technological product. The difference with drugs is that their effectiveness is extremely hard to judge without extensive head-to-head comparisons, and they can have disastrous consequences when they fail. When you factor in the costs of not only developing a single drug, but all the failed products that had to be explored in order to find it, it all adds up to a huge amount.

There is no “easy way” to develop safe and effective drugs. For every omega-3-acid out there, there is also the possibility of a hydroxycut or ephedra. Without rigorous testing we have no way of sorting out anecdotes from actuality, and the probability of any single substance being a good and safe therapy is…well…about 20 in Hundreds of Thousands.

Do I think that drugs are currently overpriced for what goes into them? Absolutely. Are corrupt insurance companies exploiting patients in order to make a buck? Sure. Are pharmaceutical companies spending too much money on advertising and “me-too” drugs, rather than genuine novel research? You betcha.

But pharmaceutical research is f*cking hard, and passionate scientists give the work of their lives just hoping to be lucky enough to be working on that one successful project that could improve people’s lives. Commenters, please don’t trivialize the amount of time and effort that goes into making sure that the drugs we use are effective and safe.

Bix said...

I think rationing, or reallocation, or whatever word you want to use (unfortunately, different parties are latching onto different words for effect. But these concepts are, in essence, the same thing.) is needed. Our resources are limited, and IMO we want to use them to cover the most people, with the best care.

If we have 10 kidneys and 100 people on a kidney transplant list, I think it's fair to discriminate/ration. We don't have 100 kidneys, we have 10. It's hard, some won't get a kidney and will die sooner because of it. I don't think it's as fair to give the kidney to the highest bidder as it is to give the kidney to someone who is more likely to live a long productive life afterwards.

Bix said...

Nice commentary, y2fizzy. I agree. I don't think the work that goes on behind the scenes - by scientists, engineers, technicians, etc., the real laborers (in any field) - gets enough credit.

I do think though that the pharmaceutical industry invites criticism for the reasons you described in your next-to-last paragraph.