Treatments With Limited (or No) Benefit
Health system reform will not occur until our communal dollars for health care, rather raised through taxes or premiums, are spent only on efficacious and necessary interventions. Inappropriate care is commonly delivered, paid for by the community with an enormous price tag. Whether it's the back fusion surgery for uncomplicated degenerative disc disease or the powered wheelchair that the manufacturer promises that Medicare will pay for, Americans suffer from a surfeit of health care. A recent NY Times editorial made this point using two drugs developed for cancer chemotherapy (find the opinion piece here). Excerpts:
The unaddressed issue, however, is whether public and private insurance should continue to pay the staggeringly high cost — reaching $88,000 and $93,000 in some cases — for drugs that offer modest help to the typical patient.
Sooner or later, as the nation struggles to contain health care spending, we may need to devise measures to determine whether very high-priced drugs provide enough medical benefit to warrant paying the bill.
Neither the Food and Drug Administration, which decides which drugs can be marketed, nor Medicare, which decides which treatments to cover, considers costs.
Last week, the Centers for Medicare and Medicaid Services decided that Medicare would pay for the use of Provenge, made by Dendreon, for men whose prostate cancer has spread beyond the prostate gland, is no longer responding to hormone therapy, and is causing few or no symptoms. The drug, tailor-made for each patient to spur his immune system to attack the tumor, costs $93,000 for a course of treatment, far more than most patients can pay. In the critical clinical trial, it extended median survival time by only four months compared with a placebo.
In a second case, Medicare said it would pay for an expensive drug that provides almost no benefit for the typical woman with advanced breast cancer. The drug, Genentech’s Avastin, costs $88,000 a year. In clinical trials, when combined with other drugs, it delayed the median time at which tumors started to grow worse from one to 5.5 months. But it failed to extend the lives of patients or improve their quality of life, and in some patients it caused severe side effects, like gastrointestinal perforations and hemorrhaging.
Based on these results, an advisory committee to the F.D.A. recommended rescinding approval for use of Avastin in breast cancer. The final decision will be made by the F.D.A. commissioner. Whatever the F.D.A. decides, Medicare will keep paying for Avastin for those with advanced breast cancer, and some private insurers may do so as well. Some women believe the drug has prolonged their lives even if it has failed to do so for the typical patient. Whether the drug is worth its high price is a question our health care system is currently unprepared to answer.
The Utah Healthcare Initiative proposes that a new commission be formed and given the responsibility to define a health benefit package for all Utahns based upon what clinical science supports as the least expensive, effective option for necessary medical care. This benefit package will be what communal dollars will fund for Utahns. Persons who desire to have health care interventions not on the list will be required to pay for those services themselves. Organizing and maintaining a list of clinically effective interventions will be difficult, but not impossible. What has so far proved impossible is to have a mature public discussion about the necessity of limiting the demand for the public to pay for whatever treatments American patients may want, regardless of the lack of clinical science supporting many interventions.
Dr. Joe Jarvis