A prominent researcher from the National Institutes of Health once told me that the best health care is "everything I choose to prescribe, order and do for my patients," according to physicians; "everything my doctor orders and everything I want," the patient's standpoint; and "as little as possible without breaking the law or losing market share" when it comes to the insurance company. The tension among these vantage points is further aggravated because neither the social, political nor medical culture of the United States has come to terms with the fact that there are insufficient resources to purchase all the health care money can buy for every citizen.
The access-vs.-resource problem is escalating dramatically as the outputs of biomedical engineering and pharmaceutical research and development continue to soar. Advances in bionics, tissue engineering, regenerative medicine, nanotechnology, gene therapy and neuro-electric circuits have produced useful and expensive options for diagnosis and treatment. This column recently covered a new treatment for hepatitis C called Sovaldi. The medication cost alone is roughly $84,000 per patient, or $1,000 per day for 12 weeks. The new medication works well and cures the disease in approximately 90 percent of cases. Is it worth it?
As new, more expensive ways of practicing medicine become available, insurance companies have no choice but to throw up increasingly onerous algorithms and guidelines for approval and pre-authorization for the most costly options. While this may be profit-driven for the for-profit payers, even for government payers the dynamic is identical. It is unwise to leave the full burden on the carriers to discern which treatments are most worthwhile.
What is the solution? The federal government should step up and set uniform national standards so that all treatments can be ranked by how much bang they give for the buck. The problem is that politicians continue to dance around the issue of rationing because it is unpopular. Anything that smacks of it reliably draws public cries equating such policies to "death panels" and "pulling the plug on Grandma." The truth is that care is already rationed but in an unequitable, unreliable and inefficient manner. A uniform national standard would benefit all concerned.
What is the best way to measure the bang for the buck for a given treatment? Health economists, statisticians, actuarials and public health pundits have developed numerous instruments to answer this question. Methods are available to compare dollars expended to produce a certain outcome, changes in life expectancy and years of productive life gained. Regarded by many as the preferred method, is a calculation that yields Quality-Adjusted Life Years, or QUALYs. It measures the cost per year of healthy life that each medical intervention offers, according to Harvard School of Public Health's Milton Weinstein. Healthy life means the ability to engage in education, productive work or enjoyable retirement. More important, QUALYs weigh the extra years of life based on how patients subjectively describe the quality of those years.
QUALYs are used to determine the cost of getting more healthy years with a new treatment compared with the standard treatment, and whether it is worth it Counseling to stop cigarette smoking, colonoscopy screenings to check for colon cancer, and prescribing beta-blockers to patients after heart attacks are examples of well-established interventions that are both effective and cost-effective, Weinstein said. Unfortunately, they are underutilized, but efforts are being made across the board to improve utilization. This is an example of the low-hanging fruit.
In addition to measuring the cost of an intervention against the QUALYs it generates, could the outcomes also be used, together with research and development costs, to modulate allowable pricing rather than simply what the market will bear?
It is time for Americans to realize that when it comes to health care, increasingly, there will not be enough resources for everyone to get all the good health care money can buy. It is time for the federal government to adopt and implement uniform standards to evaluate how much bang for the buck each treatment option offers. Delaying action will serve to only further increase health care disparities and drain the nation's coffers.