The moral, financial dilemma at the heart of health care | Jay Bookman

If such a thing were possible, it would be useful to set aside partisan sentiments for a few minutes to discuss profound questions about life and death, the obligations that we have to each other as human beings and the morally difficult choices that technology increasingly forces upon us.

Let’s begin with a new report from the nonprofit National Institute for Health Care Management Foundation. It reports that Americans “spent nearly $2.5 trillion on health care in 2009, reaching an all-time high of $8,086 per person. This per-capita spending represents an almost two-fold increase since 1997.”

Those numbers, while startling in one sense, pretty much confirm what most of us already knew. But here’s where things get more sticky:

“Spending is highly concentrated among a relatively small portion of high-cost users, with just 5 percent of the population responsible for almost 50 percent of all (health care)spending. At the other end, half of the population accounts for just 3 percent of spending.”

The tricky part, of course, is how quickly and unexpectedly any one of us can jump from one category to another. You can go for decades as part of the 50 percent that consumes just 3 percent of spending, and with one diagnosis or accident suddenly become part of that 5 percent that consumes almost 50 percent of the health care dollar.

In fact, absent sudden death by accident or heart attack, most of us will at some point make that transition from the 50 percent to the 5 percent, as will our loved ones. It is the human condition.

I feel a chart coming on.

The healthiest 50 percent of Americans account for just 3 pennies of every health-care dollar spent, while the sickest 5 percent account for 50 cents of every dollar spent on health care.The healthiest 50 percent of Americans account for just 3 pennies of every health-care dollar spent, while the sickest 5 percent account for 50 cents of every dollar spent on health care.

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Now let’s move from the statistical to the actual. The New York Times reports today on three new drugs developed to treat late-stage prostate cancer. The drugs do not cure the cancer, but they do prolong the lives of those afflicted.

Without the drugs, men with late-stage prostate cancer have a median life expectancy of a year and a half. With the new drugs, that can be extended by roughly six months, with a decent quality of life.

However, as the Times reports:

” … the price of these drugs has already stirred concerns about the costs of care among patients, providers and insurers. For example, Provenge costs $93,000 for a course of treatment, while Zytiga costs about $5,000 a month. Another of the new drugs, Sanofi’s Jevtana, costs about $8,000 every three weeks.

With other pricey drugs on the way, said Joel Sendek, an analyst at Lazard, “We could be talking easily $500,000 per patient or more over the course of therapy, which I don’t think the system can afford, especially since 80 percent of the patients are on Medicare.”

Medicare has been conducting a year-long review of Provenge, and is expected to announce on Thursday that it will cover the drug. Private insurers are expected to follow that lead. But as the Times reports, the fact that Medicare even decided to study the question became a point of controversy. “Medicare officials denied that price was the reason for the review,” the story reports. “But some patient advocates and politicians portrayed the review as a step toward rationing.”

So there’s the situation. Those men with sufficient financial resources can of course make their own decision about whether to spend $500,000 for another six months of life. But what about the rest of us? Is that an acceptable use of taxpayer money and health-insurance premiums?

And if it isn’t acceptable, what mechanism should we create to make such difficult decisions on our behalf?

I’m not looking for partisan rhetoric or bumper-sticker responses here. These are decisions that we as a society and a nation have to confront. At what point, if any, do we decide that the marginal gain in lifespan is no longer worth the investment?

Who makes that decision? And on what basis?

– Jay Bookman

The moral, financial dilemma at the heart of health care | Jay Bookman.

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