Category Archives: Ethics

That’s a deceptive title because when talking about a “free market” for products, there are many things “different” about the health care product.

I touched on a few in yesterday’s entry.

Today I’d like to explore the notion of effectiveness. In my specialty medical oncology, the only way we gauge effectiveness is through large studies of patients with the problem and comparing the outcomes (length of survival, rate of recurrence, etc). In any given patient it’s often difficult, if not impossible, to ascertain whether the treatment has actually worked or not.

For example, consider the patient with breast cancer who has had surgery with the tumor completely removed. If nothing else is done we will know in time whether the surgery cured the patient or not.

But, we often treat these patients with some type hormonal blocker (tamoxifen or another) with or without chemotherapy (called adjuvant therapy in doc talk). This can get quite expensive and is associated with frequent severe side effects.

If treated in this way and the tumor doesn’t recur, in any individual case we cannot know whether the surgery removed it all or the ensuing hormone blocking and/or chemo had some effect. Furthermore, if the tumor does recur later we are unable to determine whether the treatments delayed the recurrence.

The same is true for all other cancer types. In an individual case we simply cannot know whether the therapy given was worth the pain, cost and side-effects, unless large comparison studies of treatments and their outcomes are done.

You can of course say well, if it doesn’t return who cares. But given that tumors often recur and that there are extreme side-effects and greatly decreased quality of life from treatment and yes extreme costs, it’s important to understand whether a therapy works and just how effective it is.

Now to the difference between health care and other products. We spend literally thousands of dollars on treatments for cancer. Single drugs can cost as much as $100,000/year–that’s more than the great majority of people earn in year. In most instances, in cases of advanced disease, the improvement in survival from these agents (take Senator Kennedy’s case for example) is limited, measured in days to a few months. We, our health care non-system spend literally hundreds of billions of dollars for treatment of just these cases.

Can you name another product in this cost range, bought in the free market, that may not work? or may work for only a few days or months? or if it does work costs hundreds of thousands of dollars?

Well, that’s the situation in health care. Our costs are untenable; Our outcomes difficult to measure; and the purveyors of these products don’t want to do comparison studies to figure out what works and how it actually does work.

We do need reform!

Fascinating article in The New Yorker (June 1, 2009) on the variations in health care costs. Atul Gawande visits one of the the most expensive Health Care Markets, McAllen Texas, and looks at the reasons.

No surprises here, but nice documentation and explanation of the issues.

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Medicine’s costs confound economists. Classical economic theory (I’m not an economist, correct me if I’m misinterpreting) would have you believe that as supply increases demand is met and prices stabilize. In health care as supply increases, demand increases and prices increase. Health care is simply not a reasoned rational system.

Consider Miami: (Time, May 20,2009)

“the 2008 average private-provider costs for a Miami family of four – $20,282 – as the highest among the 14 major U.S. cities it studied, adding that more than 40% of that amount came out of Miamians’ own pockets.”

“Miami’s inordinate health-care outlay – 20% more than the national average – “is not a pretty picture,””

“That’s especially true since Miami-Dade County also has one of the country’s lowest median incomes ($43,495).”

“”South Florida has an “excess capacity of health-care providers and institutions,” Quick notes. And to make sure they all get a piece of the action, they’ve created a wasteful and ill-coordinated system of health-care redundancies, from unnecessary MRIs to inpatient treatment that too often could have been cheaper outpatient treatment. Miami-Dade, for example, has one of the nation’s highest hospital readmission rates – and more MRI machines than Canada.” (Medicynical emphasis)

Medicynical Note: For-profit medicine is simply for profit. In Miami, efficiency and even the patient’s welfare comes second. Can we learn from Miami?

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Gifts from drug companies to doctors continue despite reports to the contrary. Companies claim that such gifts are ethical and necessary. The NY Times notes:

“Drug companies spend billions (medicynical emphasis) of dollars wooing doctors – more than they spend on research or consumer advertising. Much of this money is spent on giving doctors free drug samples, free food, free medical refresher courses and payments for marketing lectures. The institute’s report recommends that nearly all of these efforts end.”

Imagine the cost savings to consumers if drug companies spent less on marketing. These companies claim it takes $800,000,000 to bring a new drug to market. How much of this inflated figure is gifts to doctors aimed an influencing their treatment decisions? If we presume the NY Times is correct and more is spent on gifts and advertising then research then the real cost of new drugs is significantly less than companies claim. Guess who ultimately pays for all this?

With drug prices increasing faster than any other part of health care expenditures is it too much to ask, as the IOM (Institute of Medicine) does, that companies and docs forgo this unethical practice?

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