Monday, August 22, 2011

Patients and Doctors Need Skin in the Game for Appropriate Care

Dr. Victor Fuchs, Ph.D. wrote an op-ed in the New England Journal of Medicine about "The Doctor's Dilemma - Delivering Appropriate Care".  Physicians are trained to deal with each patient one at a time and to make decisions based on that patient alone.  Now we are in an era when the high cost of treatment can actually bankrupt the system.  Rising health care costs are everyone's problem.  Employers are shifting insurance costs to workers and another article mentioned health costs as the biggest cause of bankruptcy.  Since the biggest driver of health expenditure is the doctor's pen, we can no longer think it is someone else's problem to solve.

A new Seattle Genetics cancer drug (Adcetris) will cost $121,000 for a course of treatment to treat Hodgkin's lymphoma. A new prostate cancer vaccine, Provenge, will cost $93,000.   When the FDA approves new drugs, they do not look at cost or cost/benefit ratios.  Most of the new drugs approved by the FDA offer marginal improvement over what is already available. The same is true for new medical devices (artificial joints, heart valves, robotics, and new scanners).

Is it worth $121,000 to live an extra 3 months?  What about an extra 6 months?  What about living an extra 6 months but spending most of that time in the hospital with serious complications? If the hospital down the street has a new $10 million dollar MRI scanner, to be competitive every other hospital has to buy one.  Does that raise the standard of health in society?  No, but it certainly drives up the cost of care for everyone.

None of these are easy questions and there are no easy answers.   What is "appropriate care" and who should be responsible for making cost-effective decisions?   On one hand we are seeing a Nationwide shortage of common drugs that are widely used because they are generic and the profit margin has disappeared for the pharmaceutical manufacturers. (I wrote about this a year ago!) The number of drug shortages has tripled since 2005.  A common cancer drug, Doxil, cannot be found and similar shortages of common antibiotics and anesthesia drugs are in short supply.  This is happening at the same time as the new $121,000 cancer drug is announced.

Make no mistake, we do have a fixed health care budget.  The Medicare bank is broken and the wave of baby boomers hitting Medicare age is just beginning.  Tough as it is, we need to develop policies that will allow everyone to live long and healthy.  We need to look out for the common good and society as a whole.   Determining appropriate care, based on our best science and evidence is a critical first step.

Doctors need to pull their ostrich heads out of the sand.  Patients need to quit demanding the "new new thing" that they read about or see on TV.  Everyone needs to know what items, tests and drugs actually cost.

Patients and Doctors need to tackle this one together and neither patients nor physicians have the luxury any longer of having unlimited health care resources without the responsibility of who will pay for it.

10 comments:

Jo Southard said...

Well written! Thank you, Toni!

Toni Brayer, MD said...

And thank you, Jo!

Michael Kirsch, M.D. said...

Yes, Fuchs' piece was well done. The incentives for overutilization are potent. There are many forces encouraging physicians to order expensive care that our patients don't have to pay for. Someone outside of the exam room has 'skin in the game'. Nice post.

Terence Coughlin said...

You've boiled the root of the cost problem down to its bare elements here in accessible terms, nicely done. There is no shortage of commentary out there on this topic, but you've gotten straight to the issue and written something easily understandable.

It is nice to read opinions on the cost problem from the physician point of view, rather than the government or payer point of view. I think all sides agree that there is a huge problem that is only getting (much) worse, but as soon as discussion turns to solutions, well, that's when sides are taken, talking points emerge, and feet dig in.

The dilemma to me is how to have a rationale conversation on solutions. The problem is national in scope, but as soon as the conversation starts at the national (political) level, ideologies erupt and in a matter of moments we're buried in maddening distractions such as death panels and leaving grandma out to die. The most productive conversations I've encountered are local (either in-person or on more rational corners of the web, such as this blog and others). At this level, calmer heads and appreciation for others' viewpoints often blossom, but the scope of the problem is so overwhelming, there is little that can be done to make any practical difference or improvements beyond conversation, combined with the hope that civility and compromise will appear at the national level.

I'm not optimistic.

Anonymous said...

Your blog is really great. The cost of health care is so complex but until we really start breaking it down and taking the special interests away we will never make progress. I agree with Terence Coughlin about the politics always interfering with change. There are too many stakeholders who have "skin" in the game and they are not willing to change anything.

Dawn McDonald said...

Well said, Toni!

Paula Dhannda, MD said...

Great post to share with my patients. You made a complex issue understandable for all.

Paula Dhannda, MD said...

Great post to share with my patients. You made a complex issue understandable for all.

Anonymous said...

Well said, succinctly and clearly. And sorely needed. It's now about ethics in economics. Time to replace profits motivated by greed with profits cultivated by ethics. Patients and physicians together can begin that movement by reducing demand for the high cost, minimal advantage new products. We need your post and similar articles published more frequently and in more places.

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