http://www.nytimes.com/2008/07/06/health/06avastin.html?ex=1373169600&en=194376ea36fc6226&ei=5124&partner=permalink&exprod=permalink
I keep thinking about this article that I read in the New York Times last weekend. The article addresses the moral dilemma surrounding Avastin, a widely used cancer drug of astronomical price whose treatment potential has recently been called into question. [If your curious, Avastin works by blocking VEFG (vascular endothelial growth factor), thereby preventing tumors from growing blood vessels]. Avastin, currently used by 100,000 Americans, costs $4,000- $9,000 a month (generating about 3.5 billion dollars a year in revenue for Genentech). In the first clinical trial, Avastin showed no statistically significant prolongation of life in patients with advanced breast cancer. In a second trial, Avastin was shown to add an average of for additional months of life to patients with advanced colon cancer. It was FDA-approved in 2004 and has enjoyed great success, being prescribed on and off-label to patients with many types of cancer. In a recent, larger, study, no statistically significant difference was proven with Avastin.
The article raises important question- how great a disparity between price of treatment and value of treatment will society allow? And who gets to make the decision? The Declaration of Independence tells us that we are all entitled to "Life, Liberty and the Pursuit of Happiness". How far does that entitlement go? Does every person "deserve" every possible treatment, with no economical constraints? Health care is the only sector of our capitalist economy where there is such exorbitant spending with such little accountability. We are in a indisputable health care crisis. Tremendous insurance costs render 47 million Americans uninsured. General Motors is laying off workers by the thousands because it can't afford the health insurance for it's employees and retirees. In light of this, I wonder how Medicare justifies paying for 80% of an off-label treatment that, in the best (colon cancer only) clinical trial, was shown to add only four months of life. (I say Medicare, because that is the insurance quoted in the article, I don't know the reimbursement ranges of private insurances).
Having said this, no one close to me has ever been offered Avastin. Put in that position, who knows how much I would think the hope of four more months would be worth? How can you put a price on someones life? And isn't that what health insurance is for, anyway? To the last question, I answer no. Health insurance, whether self-paid or otherwise acquired, must not become a carte blanche for any possible intervention in the world. There must be a basic, reasonable amount of care paid for by insurance. Resources are limited and finite. Drugs that have not proven valuable (meaning a benefit appropriate for the cost) must be viewed as elective treatments. In the same way that health insurance will pay for the removal of a mole that may be cancerous (and thus detrimental to the health) but not a mole for purely vanity purposes, Avastin must be judged on it's actual, demonstrable benefit. If this benefit is not worth it's cost to the insurance company, the patient must forgo the treatment or find alternate means for affording the treatment. This will force the price of Avastin to adjust to the level that a patient deems worth it. The supply will have to meet the demand in terms of price. Either Genentech will find a way to make Avastin affordable enough to the people who want it, or Avastin will no longer be available.
Of course there must be more clinical trials to discern the efficacy of Avastin. At the same time there must be large financial incentives for the companies to find a more effective and more affordable drug. In the mean time, Genentech stock holders can cross their fingers that insurance companies will continue to pay upwards of $100,000 dollars a year out of a fear that they will look like bad guys if they refuse to pay.
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5 comments:
If only all health care givers were so sensible! Thanks for being you, Nurse Molly!
I also saw this article, and had a similar reaction. So the issue becomes are all Americans entitled to the best that money can buy? [I'll admit I dont know enough about Avastin so Im going to say this much more broadly.]
Why should there only be two choices if in fact more than one treatment option exists? And if two do exist, say a generic and a regular, with marginal benefits coming at great cost, who should make the decision?
Personally, I think health plans need to create a greater split to encapsulate the fractured market, and of course this would require a full disclosure of exactly what the plan offers, in laymen's terms.
So in my perfect world, your premium would reflect what you would expect, and if there were no generics available, then most plans would include the higher cost newer drug.
Why should everyone pay the actuarial cost for $200k prescriptions if not everybody would want that absurdly overpriced drug anyway?
BTW - NurseMolly keep this blog alive, I really like where you're going...
Thank you for a very coherent treatment of complex issues. What would a basic level of health care be?
Now,talk about hot topics! Prescription drugs. Who mandates use? cost? efficacy? Drug companies and PBA's (Prescription Benefit Administrators). For years, Americans have traveled across the borders to obtain pharmaceuticals that are being manufactured here but not approved for use in the country - why because we do not have equal access. There are numerous disparities in the health care field. Will this election year bring that change?
In respones to Aron's comment, I think we are in agreement; "entitlement" is a dangerous concept. Which privileges are conferred upon a human being by virtue of being born in a certain location? If Joe was born in Detroit and John was born in Darfur, does Joe deserve a $1,000 CT scan to rule out the miniscule chance that his headache might be due to something more serious than a migraine? (Also: does this answer change depending on wether Joe has insurance?) Does John not deserve a $4 malaria vaccine? Obviously, that is an extreme example, but I think that the limited resources in third world countries provide valuable insight into the concept of resource allocation. I am not advocating that Americans should forgo life-saving blood transfusions because not every human being is able to receive one in a time of need. What I am advocating is increased transparency in the actual cost and perceived value of limited healthcare resources. I am advocating informed decision making by providers, consumers, insurance companies and the government. We, as Americans, can not shy away from difficult conversations (by simply throwing more money at the problem). We can not say we are entitled to the best money can buy when we do not even know who is paying the price.
I absolutely think that we must designate some party which will make the decisions about appropriate costs. The NYT article mentions that an institution that advises the British government recommended against the use of the drug in their socialized healthcare system. When I read that, I thought, "how do we get those guys?". As I read on, however, the article reported that the FDA approved Avastin despite the rejection of the drug on a cost-benefit analysis by an outside expert panel. What or who was able to pressure the FDA to overturn the ruling of third party experts?
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