Special Feature
Lessons in Supportive Care, IX: Do Medical Care Interventions Ever Save Money? Defining the New Battleground of Cost Control
By Thomas J. Smith, MD
Hype, Hope, and HER-2/neu
I snarfed someone's discarded Wall Street Journal on the plane home from the ASCO meeting in Los Angeles. The meeting had been filled with hope for new treatments and rational drug design: antibodies to HER-2/neu nearly doubled the response rate and disease-free interval in breast cancer, adding paclitaxel after "AC" improved results, finally a decent treatment for refractory colorectal cancer. I had ignored the hype as much as possible since I knew these advances firsthand. I had seen one of my 40-year-old breast cancer patients recur after high-dose chemotherapy, and then have 15 great months in "CR" with no side effects to anti-HER-2/neu.
But, the Journal was disturbed. Minneapolis, the mecca of managed care, was seeing 8-15% rate hikes this year in health maintenance organization contract requests. That's right, 8-15% in one year. And, the rate hikes were across the board for nearly all providers.
The prices rumored for some of the new drugs from the ASCO meeting were astonishingly high: $2400/month for irinotecan for colorectal cancer; $2000/week for antibodies to HER-2/neu; $1000/month for capcitabine (Xeloda). Add that to her erythropoeitin at $15,000 a year and about $2,000 of filgrastim a month . . .
No wonder the HMO costs were going up. And the Journal article confirmed it-much of the cost increase was due to pharmaceuticals that patients wanted.
So, I wondered, do medical interventions ever save money? And, how are we going to deal with these new drugs?
| Table Cost Saving Medical Care |
|
| Intervention | Savings |
| Having a nurse-manager to coordinate end-of-life care (Raftery JP, et al. Palliat Med 1996;10:151-161.) | 41% |
| Total hip replacements | Always cost saving up to age 80 |
| Screening for childhood hearing loss | |
| Pneumococcal, Influenza, Hepatitis B vaccine | |
| Allogeneic bone marrow transplant for acute myeloid leukemia in second remission | $-24,500/life year |
| Filgrastim-primed stem cells vs. bone marrow for high-dose chemotherapy support | 19% savings, equal clinically |
The Short List of Cost-Saving Interventions
I ran a quick search and came up with a short list of medical care that actually saved us money. A really short list. (See Table.)
I came up with a lot of things that were "cost-effective," which means the ratio is less than $50,000/year of life gained, or whatever the seller wants it to mean. But, that still means additional money to gain that time. As Jeffrey Silber, MD, once said, "you can go broke doing cost effective care."
The key to understanding why more medical care does not save money is in the equation for cost effectiveness:
The only way for a medical intervention to actually save society money is to cost less, unless it is tremendously effective and saves lives. The new intervention must be priced less than the old one that it replaces.
Patient Demand
I had a dozen e-mails, phone calls, and faxes waiting for me from patients who wanted HERCEPTIN, Xeloda, both, the extra 1% that CAF gives over CMF, or some other thing they heard about. I spent an hour on the phone tonight with a friend of a friend helping them figure out what to do until HERCEPTIN is on the shelves.
Today, I counseled a 42-year-old woman with recurrent breast cancer, HER-2/neu-positive, about her options now that alternative medicines have not worked. Doxorubin alone or with a taxane, a taxane alone, either followed by high-dose chemo if she has a great response; 5-FU, leucovorin, and mitoxantrone if she really did not want to lose her hair; HERCEPTIN; etc. The list gets longer and longer.
When I told her insurance companies might not cover HERCEPTIN or Xeloda, she looked shocked, then told me that "Well, I guess the cost doesn't matter if my life is at stake." She is not well-to-do, either.
Juxtaposed Disparity
Two days after ASCO, my wife was testifying before the U.S. Senate Committee on Native American Health. (We had worked on an Indian Reservation in North Dakota for some years before coming back to practice in Virginia, and she still works with the American Academy of Pediatrics to help solve childhood problems.) While we spend nearly $4000 per person on health care in the United States, the Indian Health Service spends only $1600-and that is shrinking. Childhood mortality on the reservations is higher than everyplace but Haiti in this hemisphere. One of every eight men dies before age 25.
Where Are We Heading?
I can envision the fights that I will have in the next several months. The first would be with insurers about covering new drugs that don't look that exciting to them. After all, they are not dying 41-year-olds with kids aged 3, 5, and 9. I suspect they got blindsided by these new drugs and have no policy in place. I will find out later this morning with a round of phone calls.
The second would be with my own P & T Committee. We run a closed formulary, zero sum budget model here to keep costs down. After all, some 20% of our medical ward patients are indigent, and no other model would work. Adding new drugs will drive up the cost and something else must go.
The third would be with my colleagues who want all these drugs available so that we can help to our maximum ability, and to keep up with the Joneses.
This is heading us to an explicit two-tier system, with one group being able to get HERCEPTIN, erythropoetin, etc., and one group making do without.
One medical ethicist quipped that the least ethical means of using limited resources was to keep using them in an unexamined way.
Contract Health Meetings, Indian Health Service Style
At the Indian Health Service, we had limited dollars for "out-of-network" care, which we did by contract. The tribal council made a general list for priority: emergency, OB, surgery, orthopedics, etc., all the way down to cosmetic surgery. During the week, we kept a list of all the unmet demands: little Johnny and his corrective shoes, Mrs. X with her needed artificial hip, and so on. At a one-hour meeting, we shared the stories and made funding decisions. Those passed over went into next week's batch.
HMO chief: "We have $12,000 this month for palliative chemo. Let's get started." Dr. S: "Mr. G. is a 74 year old with recurrent colon cancer who had severe FU dermatitis four years ago with adjuvant Rx. I want to use irinotecan at $3200/month so he can live five months longer." Dr. R: "Well, Mrs. C is a 50 year old with sarcoma, refractory to ICE, and adriamycin, and I want to give her a two-month trial of vinorelbine, with a 15% response rate at $2000/month." Cardiologist: "Remember how I couldn't get my anti-clotting agents last month? Forget this palliative chemo stuff!" Fighting ensues.
I simply don't see any other way around it . . . sooner or later, someone will have to say "no" to some drug requests-unless we want to live with 8-15% medical inflation again. And, that's not fair to our kids.
Solutions
There are none, that I can see. This is not Godzilla to be vanquished. This is a monster of our own making, but it's not necessarily spawned by greed or nuclear waste. The drug companies are doing what they are supposed to be doing.
Clearly, though, there must be some limits on pricing and drug availability. Individual practitioners should generally not make rationing decisions on their own-it's too easy to be biased. I predict that upward cost pressures will force the insurers to address the limits of care by pushing capitation even more, so that the risk lies with us. If so, then I hope that our professional societies and organizations can help us make the right decisions for our patients.
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