Wednesday, December 3, 2008

What Price is Life?

The subject of today's blog - What Price Is Life? - may sound like I am heading into the realm of philosophy instead of public policy. But it is a question that the country will need to consider as it explores ways to reduce health care costs.

On Sunday, the Washington Post reported that many experts believe that the U.S. "is not getting what we pay for" and that "better data [on the comparative effectiveness of different treatments] may address what Dartmouth College researchers describe as large, 'unwarranted' variations in medical spending ... as much as 30 percent of medical spending - or $700 billion - does nothing to improve care."

The idea of funding research on comparative effectiveness is supported by Peter Orzag, former head of the Congressional Budget Office and President-elect Obama's choice to head the White House budget office, and by former Senator Thomas A. Daschle, Obama's choice to head the Department of Health and Human Services.

ACP supports more research on comparative effectiveness. In an article published in the Annals of Internal Medicine earlier this year, ACP proposes that such research should include both relative clinical efficacy and relative cost-effectiveness:

"Cost-effectiveness information is a necessary complement to comparative clinical effectiveness information for all health care stakeholders. This information will help patients and their personal physicians make treatment decisions that better reflect the needs and preferences of the patient and support the profession's commitment to a just distribution of finite resources."

Written on behalf of ACP's Medical Services Committee and based on a broader ACP position paper, the authors acknowledge "concerns by patients and their advocates that use of any cost data will inappropriately limit access, be used primarily for cost-containment, and be a substantial step toward rationing of care" but finds that with "appropriate safeguards ... use of cost-effectiveness data when making policy is a reasonable approach to controlling the escalating rise in health care."

One only needs to look at Great Britain to understand why introducing comparative effectiveness research into the U.S will be controversial.

In today's New York Times, reporter Gardiner Harris tells the story of a patient, Mr. Bruce Hardy, whose kidney cancer spread to his lungs. Britain's National Health Service denied him access to a pill, called Sutent, which delays cancer progression for six months at an estimated treatment cost of $54,000. The story reports that "any drug that provides an extra six months of good-quality life for 10,000 pounds - about $15,150 - or less is automatically approved [by the National Health Service], while those that give six months for $22,750 or less might get approved. More expensive medicines have been approved only rarely." The article ends with a heart-tugging comment from Mr. Hardy's wife of 45 years:

"It's hard to know that there is something out there that could help but they're saying you can't have it because of cost," said Ms. Hardy, who now speaks for her husband. "What price is life?"

It is unlikely that the United States will use comparative effectiveness research to deny coverage for drugs based on a dollar threshold of extra months of "good-quality" life.
But as the U.S. explores ways to reduce health care expenditures, questions of cost and benefit - and yes, the price of life - will be part of the conversation.

Today's questions: Do you believe that the United States should fund independent research on the relative comparative effectiveness and use such research to inform clinical and coverage decisions? Should relative cost-effectiveness be part of the assessment?

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