By Kate Scannell MD, Contributing columnist Bay Area News Group
PUBLISHED IN PRINT 10/04/10
"THE BIG C." It's always been difficult for doctors, hospital administrators and health care executives to "spell it out." It terrifies American politicians. Patients tend to confront it only when it afflicts them or their loved ones. Everyone is so afraid of discussing the Big C, that we prefer to remain silent all the while it eats like a cancer through our national economy and health care infrastructure.
I am referring to health care "Cost." Today I'm writing about a new study that raises the specter of the Big C in a manner we can ill-afford to ignore. It also forces this question: When we pay for health care, just what are we buying -- with our pocketbooks, our downward salary adjustments for increasingly expensive insurance benefits, and our taxes funding government-sponsored health programs like Medicare? When does a costly new drug or medical device become worthy of its expense to us?
The new study, and critic's response
Published in last week's New England Journal of Medicine, the study involved about 3,000 people, each with a blood clot involving a surface vein on the leg. In and of itself, a "superficial-vein thrombosis" is a somewhat common and usually benign condition. Still, for a small percentage of people, the clot later extends into a deeper vein, creating a "deep venous thrombosis" or "DVT."
The major significance of a DVT is that, on rare occasions, it can loosen from the vein and travel the bloodstream to the lungs, creating a potentially fatal "pulmonary embolus" or "PE."
For 45 days, one half of the group with superficial-vein clots received daily injections with a drug called Arixtra, while the other half received placebo injections.
In the end, three persons in the drug group -- versus 20 in the placebo group — developed a DVT or PE. No one in either group died. The researchers found that 88 people with superficial-vein clots had to be treated with Arixtra in order for one person to benefit (that is, avoid a DVT or PE).
But a critic of the study raised the C word in an accompanying editorial. He noted that this 1-in-88 "benefit" cost about $1,900 per treated patient "without any lives saved." He boldly suggested that the Food and Drug Administration evaluate the "cost-effectiveness" of Arixtra before it's unleashed into the world as a routine treatment for superficial-vein thrombosis.
Drawing the line
So, the basic question becomes: Where do you draw the line when you decide whether a new drug or medical device is worth its cost, or whether it should be covered by an insurance company? Do you decide when one person benefits out of every 10, or 88, or 2,000 people who are treated? At what price -- when the treatment per person costs $10, $1,000, $50,000 or a $1 million?
These coverage decisions are made every day by private insurance executives. They try to evaluate new medical interventions that could benefit their policy holders, while at the same time keeping premiums affordable and generating company profits or operating expenses. It is not an exact science.
But where they draw that line affects you as a policyholder. Not only does it limit your potential entitlements while permitting others, it also affects your ability to afford your insurance premium.
If your insurance company's executives approved coverage for every new medical intervention -- regardless of its cost or its track record in benefiting patients -- you can be certain that your monthly premium would rival the national debt.
That's because, even if you never swallow the new $60,000 pill or undergo the $100,000 stent surgery, some people within your insurance pool will. When you share the pool with others, you also share the costs of its upkeep.
The same is true for Medicare coverage decisions. Enrollees may have to face higher fees, and taxpayers pay more taxes to keep that program afloat.
Challenges, conundrums
So how would you advise your own insurance company about covering Arixtra for everyone who develops a superficial clot? Do you think the drug is "worth it?"
Consider, too, your advice about covering each of these cancer drugs:
• Erbitux, which might extend survival by 1.2 months at a cost of $80,000?
• Avastin, 1.5 months at a cost of $91,000?
• Tarceva, 10 days at a cost of $16,000?
We should not dismiss these examples as outliers. In fact, as reported in 2009 in the Journal of the National Cancer Institute, "greater than 90 percent of the anticancer agents approved by the FDA in the last four years cost more than $20,000 for a 12-week course of treatment."
Other Big C words for health care -- collective, consensus, community, communication and the care in health care
Opinions about coverage decisions often vary depending on one's perspective -- as a patient, a family member, a doctor, a hospital administrator, an insurance executive or Medicare trustee. For example, as a Medicare trustee I might decide against covering a $95,000 treatment that could extend a cancer patient's life by a single month -- until, perhaps, I become a cancer patient who might gain that extra month of life with treatment. Or as a patient, I may want my insurance company to approve coverage for anything I might ever want — until I realize that such an attitude, extended to its million other insured subscribers, has made my premiums unaffordable.
Besides political good will and public civility, what's missing in our health care debates about insurance mandates and coverage decisions is the big-picture perspective that belongs to the collective view.
What's missing is social solidarity and consensus, and a fraternal spirit that engages us as stewards of our community and its health.
Until we care about that, I doubt we'll ever succeed in reigning in the Big C in the service of good, quality, affordable health care. I think we are all worthy of that.
Kate Scannell is a Bay Area physician and syndicated columnist. She is the author of the memoir "Death of the Good Doctor" and the novel "Flood Stage."
Copyright Kate Scannell 2010
PUBLISHED IN PRINT 10/04/10
"THE BIG C." It's always been difficult for doctors, hospital administrators and health care executives to "spell it out." It terrifies American politicians. Patients tend to confront it only when it afflicts them or their loved ones. Everyone is so afraid of discussing the Big C, that we prefer to remain silent all the while it eats like a cancer through our national economy and health care infrastructure.
I am referring to health care "Cost." Today I'm writing about a new study that raises the specter of the Big C in a manner we can ill-afford to ignore. It also forces this question: When we pay for health care, just what are we buying -- with our pocketbooks, our downward salary adjustments for increasingly expensive insurance benefits, and our taxes funding government-sponsored health programs like Medicare? When does a costly new drug or medical device become worthy of its expense to us?
The new study, and critic's response
Published in last week's New England Journal of Medicine, the study involved about 3,000 people, each with a blood clot involving a surface vein on the leg. In and of itself, a "superficial-vein thrombosis" is a somewhat common and usually benign condition. Still, for a small percentage of people, the clot later extends into a deeper vein, creating a "deep venous thrombosis" or "DVT."
The major significance of a DVT is that, on rare occasions, it can loosen from the vein and travel the bloodstream to the lungs, creating a potentially fatal "pulmonary embolus" or "PE."
For 45 days, one half of the group with superficial-vein clots received daily injections with a drug called Arixtra, while the other half received placebo injections.
In the end, three persons in the drug group -- versus 20 in the placebo group — developed a DVT or PE. No one in either group died. The researchers found that 88 people with superficial-vein clots had to be treated with Arixtra in order for one person to benefit (that is, avoid a DVT or PE).
But a critic of the study raised the C word in an accompanying editorial. He noted that this 1-in-88 "benefit" cost about $1,900 per treated patient "without any lives saved." He boldly suggested that the Food and Drug Administration evaluate the "cost-effectiveness" of Arixtra before it's unleashed into the world as a routine treatment for superficial-vein thrombosis.
Drawing the line
So, the basic question becomes: Where do you draw the line when you decide whether a new drug or medical device is worth its cost, or whether it should be covered by an insurance company? Do you decide when one person benefits out of every 10, or 88, or 2,000 people who are treated? At what price -- when the treatment per person costs $10, $1,000, $50,000 or a $1 million?
These coverage decisions are made every day by private insurance executives. They try to evaluate new medical interventions that could benefit their policy holders, while at the same time keeping premiums affordable and generating company profits or operating expenses. It is not an exact science.
But where they draw that line affects you as a policyholder. Not only does it limit your potential entitlements while permitting others, it also affects your ability to afford your insurance premium.
If your insurance company's executives approved coverage for every new medical intervention -- regardless of its cost or its track record in benefiting patients -- you can be certain that your monthly premium would rival the national debt.
That's because, even if you never swallow the new $60,000 pill or undergo the $100,000 stent surgery, some people within your insurance pool will. When you share the pool with others, you also share the costs of its upkeep.
The same is true for Medicare coverage decisions. Enrollees may have to face higher fees, and taxpayers pay more taxes to keep that program afloat.
Challenges, conundrums
So how would you advise your own insurance company about covering Arixtra for everyone who develops a superficial clot? Do you think the drug is "worth it?"
Consider, too, your advice about covering each of these cancer drugs:
• Erbitux, which might extend survival by 1.2 months at a cost of $80,000?
• Avastin, 1.5 months at a cost of $91,000?
• Tarceva, 10 days at a cost of $16,000?
We should not dismiss these examples as outliers. In fact, as reported in 2009 in the Journal of the National Cancer Institute, "greater than 90 percent of the anticancer agents approved by the FDA in the last four years cost more than $20,000 for a 12-week course of treatment."
Other Big C words for health care -- collective, consensus, community, communication and the care in health care
Opinions about coverage decisions often vary depending on one's perspective -- as a patient, a family member, a doctor, a hospital administrator, an insurance executive or Medicare trustee. For example, as a Medicare trustee I might decide against covering a $95,000 treatment that could extend a cancer patient's life by a single month -- until, perhaps, I become a cancer patient who might gain that extra month of life with treatment. Or as a patient, I may want my insurance company to approve coverage for anything I might ever want — until I realize that such an attitude, extended to its million other insured subscribers, has made my premiums unaffordable.
Besides political good will and public civility, what's missing in our health care debates about insurance mandates and coverage decisions is the big-picture perspective that belongs to the collective view.
What's missing is social solidarity and consensus, and a fraternal spirit that engages us as stewards of our community and its health.
Until we care about that, I doubt we'll ever succeed in reigning in the Big C in the service of good, quality, affordable health care. I think we are all worthy of that.
Kate Scannell is a Bay Area physician and syndicated columnist. She is the author of the memoir "Death of the Good Doctor" and the novel "Flood Stage."
Copyright Kate Scannell 2010