Patients Forced to Choose Life or Death 8/13/2006 8:12:40 AM
High-Priced Drugs, Implants Force Patients to Make Life/Death Decisions
Dying of lung cancer, Carolyn Hobbs tried a new biotechnology drug that produced an unanticipated side effect: acute sticker shock. She was waiting for her second treatment in a hospital near Denver less than two years ago, when someone from the business office marched in to warn that her share would cost more than $18,000, since the drug wasn't insured for her type of cancer. Maybe this new drug, Erbitux, could extend her life by a small fraction, but she wouldn't be cured. "She was just very frugal, and she said it wasn't worth it," her husband Larry remembers. So she refused the treatment. Though she initially refused Erbitux because of cost, she ultimately arranged to get that drug and three other biotech drugs for free, with help from her doctor, hospital, Medicare and the drug industry. Her husband says she managed to keep a reasonable quality of life, even through most of her final months. She died in November. To this day, her husband isn't quite sure how much was spent on treatment.
More patients are confronting this wrenching decision, as the latest generation of pricier cancer drugs and heart implants stretches out the final months of advanced disease, and pharmaceutical companies continue to rake in obscene profits at the cost of the living and dying.
Whoever pays, costs undenialbly are up. New drugs and care costs several times more than the older treatments it supplements or replaces. A last-resort cancer drug can cost up to $50,000 a year, if patients survive that long, with insurance typically picking up at least two-thirds. A mechanical heart pump can cost more than $200,000 when you add in hospital care. Reports of these breakthroughs, which often fail to mention the price, may have intensified the distinctly American tendency to view death almost as a personal choice, suggest doctors and ethicists.
From their first day of medical school, doctors are trained to do their utmost for patients.
While doctors advocate for the interest of dying patients, they may also be subtly swayed by earning their livings partly from providing this care. And many patients don't fret, because they are insulated from huge payouts by insurance. The average patient in the best medical test so far lived less than nine more months, once heroic, expensive treatments were done.
Federal safety regulators do not regulate the price of end-of-life treatments. They evaluate only if drugs or devices work, not how well they work for their prices. Medicare, which insures about 80 percent of dying Americans, makes no acknowledged evaluation of cost in deciding what to cover. It is not allowed to negotiate for lower drug prices, which keeps the price high, when there is no incentive to reduce it. Under such pressures, the $1.9 trillion spent on U.S. health care in 2004 will balloon to $4 trillion by 2015, federal forecasters project. In that year, health spending, which claimed 16 percent of the economy in 2004, would consume 20 percent and cost the average American $12,400.
Despite official denials, the federal Medicare program makes subtle cost evaluations, says Dr. William Maisel, a Boston heart specialist who chairs a federal committee on cardiac devices. "I think they are concerned about people using the term `rationing' or `withholding therapies,'" says Maisel, at Beth Israel Deaconess Medical Center.
Some believe the country can afford to spend even more, and that it is worth it. Others fear insurance turning into a luxury item. Some insurers already refuse to cover certain treatments. As a result, doctors send patients home to die, sometimes out of mercy. Many patients say enough is enough.
"If you've got a thick wallet or a full purse, you can get any care you want. If you don't, there's rationing for you," says former U.S. Health Secretary Joseph Califano, who later dealt with escalating health costs as a board member at Chrysler Corp.
