A year-and-a-half ago, Howard Brody of the University of Texas Medical Branch in Galveston wrote an opinion article in the New England Journal of Medicine calling on every medical specialty to develop ways of cutting the cost of care. Citing financial sacrifices that had been made by insurers, hospitals, drug and device companies in the then pending health care reform bill, Brody said physicians could do their part “if they were willing to practice more in accordance with evidence-based guidelines and to study more seriously the data on regional practice variations.”

Toward that end, he called on each specialty to come up with a list that “would consist of five diagnostic tests or treatments that are very commonly ordered by members of that specialty, that are among the most expensive services provided, and that have been shown by the currently available evidence not to provide any meaningful benefit to at least some major categories of patients for whom they are commonly ordered.”

In the NEJM last week, two oncology specialists — Thomas Smith and Bruce Hilner of Virginia Commonwealth University — took up the challenge. They created a “top five” list of common oncology practices, which, if limited to situations where they were truly clinically useful, would sharply lower the cost of cancer care. Their lead paragraph noted the need for taking these steps:

Annual direct costs for cancer care are projected to rise — from $104 billion in 2006 to over $173 billion in 2020 and beyond. This increase has been driven by a dramatic rise in both the cost of therapy and the extent of care. In the United States, the sales of anticancer drugs are now second only to those of drugs for heart disease, and 70% of these sales come from products introduced in the past 10 years. Most new molecules are priced at $5,000 per month or more, and in many cases the cost-effectiveness ratios far exceed commonly accepted thresholds. This trend is not sustainable.

Look closely at the second to last sentence of that paragraph: “In many cases the cost-effectiveness ratios far exceed commonly accepted thresholds.”  It’s worth noting that there are no commonly accepted thresholds for cost of care in the U.S. That’s not true in Great Britain, where the National Health Service, based on recommendations from the National Institute for Clinical Excellence, will refuse to pay for certain drugs when their costs exceed certain levels. But in the U.S., Medicare, which is the primary payer for most cancer care since cancer is primarily a disease of aging, is forbidden by law from taking cost into consideration. If the Food and Drug Administration has approved a specific approach, and the doctor prescribes it, Medicare will pay for it. If the oncologist tries an approach that is not specifically approved by the FDA — either as an “off label” use or combination of approved drugs — the Centers for Medicare and Medicaid Services will still pay for the treatments long as the approach is listed in clinical practice guidelines. And when it comes to most testing and imaging, most insurers including Medicare will pay for whatever the doctor orders, even though the medical literature is loaded with studies suggesting their lack of usefulness in many situations where commonly used.

That’s why oncologists themselves have to take this issue on. Here’s their top five list of new rules for controlling the cost of cancer care:

  1. Only use testing and imaging where “benefit has been shown”;
  2. Limit second-line and third-line treatments to metastatic cancer to sequential monotherapies for most solid tumors. “Patients will live just as long but will avoid toxic effects. . . Society will benefit from cost reductions associated with less chemotherapy, fewer supportive drugs, and fewer toxicity-associated hospitalizations”‘;
  3. Don’t give chemotherapy to people when their cancer has made them so weak that a positive response is highly unlikely;
  4. Lower chemo doses to eliminate the routine use of drugs that replace the white blood cells destroyed by toxic chemo drugs; and
  5. Stop treating patients if they haven’t responded to three different drug regimens — unless they are enrolled in a clinical trial actually testing the fourth regimen.

They also came up with a list of five changes in physician and patient attitudes that must take place to cut the cost of care, ranging from support for end-of-life counseling to more support for hospice and palliative care. “We understand that this will be extraordinarily difficult, since one person’s cost constraint is another person’s perceived lifesaving benefit and yet another’s income,” the two authors write. However, “there really is no other way. Our intention is to encourage other specialties to do the same and flatten the cost curve so that patients can continue to get the best new therapies.”

Now, here’s my top five list of how the editorial page of the Wall Street Journal will respond to this call for rationing based on science and common sense:

  1. It’s rationing that abrogates physician autonomy;
  2. It’s rationing that prevents individual choice in evaluating the trade-offs between benefits and risks;
  3. It’s rationing that denies very ill patients hope;
  4. It’s rationing that puts cost ahead of best practices; and
  5. Did I mention that it’s rationing?

And as far as end-of-life counseling is concerned, we’ve already heard right-wing politicians crying “death panels.”

I congratulate Smith and Hilner for taking on the Brody challenge. But there was one other issue I wish they had addressed. Why are cancer drugs of marginal efficacy so expensive? Why does a drug that extends life by a month or two cost $5,000 to $10,000 a month for the last year or two of a person’s life, thus adding up to a quarter million dollars to the cost of end-of-life care?

One could write a book about why there’s no economic justification for these sky-high prices (See this one, for instance). Last year, two Sloan Kettering researchers, writing in Health Affairs, proposed pricing new cancer drugs at the medical value they deliver — so-called reference pricing. I wrote about it here.

There’s a lot that oncologists can do to reduce the cost of care through eliminating unnecessary tests, images and treatments. But they should also begin raising their voices when they see drug companies charging an arm and a leg for products that they know, better than anyone else, really aren’t worth the money.

Merrill Goozner has been writing about economics and health care for many years. The former chief economics correspondent for the Chicago Tribune, Merrill has written for a long list of publications including the New York Times, The American Prospect, The Washington Post and Financial Times. You can read more pieces by him at GoozNews, where this post first appeared.

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59 Responses for “How to Lower Cancer Care’s Costs”

  1. Mark Spohr says:

    In the last few years I have watched several friends die of cancer. They all had “incurable” terminal cancer but they all spent literally hundreds of thousands of dollars on the advice of their doctors to “extend their lives”. From my observations, all this did was enrich doctors, hospitals and drug companies. Some of them died earlier and all of them had a much decreased quality of life.
    The latest was a friend who was Dx with laryngeal ca and underwent surgery, radiation, and chemo. He died yesterday only 6 weeks after Dx. I have no doubt that if he had been honestly treated and told he had incurable cancer, he would be alive today at home rather than spending his last 6 weeks in the hospital and ICU in considerable distress. He would eventually die at home but could be kept comfortable with his family.
    The medical profession is thoroughly corrupt.

    • Craig "Quack" Vickstrom, M.D. says:

      Obviously, I disagree with you in the general case. With regards to cancer care, I am inclined to agree with you. However, I do personally know several oncologists who tell their patients the truth and do not bilk them.

      • Mark Spohr says:

        I believe that the system is corrupt and not necessarily that individual physicians are out to “bilk” patients. It’s just the all of the financial incentives are tilted towards “full treatment” without regard to cost or benefit and it is easy for a physician to subconsciously distort “best practice” to improve his or her income.
        It’s similar to the situation with drug companies paying physicians to be “advisers”. The physicians will deny that it distorts their objective decision making but all of the research point to a profound corruption of their values.

  2. Greg Pawelski says:

    I posted a reply to Merrill’s questions of the other issue he wished they had addressed, on his private blog. “Why are cancer drugs of marginal efficacy so expensive? Why does a drug that extends life by a month or two cost $5,000 to $10,000 a month for the last year or two of a person’s life, thus adding up to a quarter million dollars to the cost of end-of-life care?”

    The challenge facing pharmacogenetics – the study of genetically determined variations in responses to drugs in humans – is the number and complexity of interactions a drug has with biological molecules in the body. Variations in many different molecules may influence how someone responds to a medicine. There is a great degree of variation in how people absorb drugs. Individuals have different levels of enzymes in the intestines and liver that breaks down drugs before they even have the chance to get into the bloodstream.
    Teasing out the genetic patterns associated with particular drug responses could involve some intricate and time-consuming scientific detective work. Unfortunately, the introduction of these new drugs has not been accompanied by specific predictive tests allowing for a rational and economical use of the drugs. However, there are a number of laboratory tests that are better able to predict the ability of targeted drugs, to produce positive clinical responders (outcomes). To exploit the full potential of targeted anticancer therapies, physicians need laboratory tests that actually match patients to specific drugs.

    No pharmaceutical company relishes turning over sizeable pieces of profitable business because a diagnostic test suggests it should. An article in Pharmaceuticalcommerce.com, Drew Fromkin, CEO of Clinical Data warned us that drug makers must drive growth, revenue, and profitability, and personalized medicine runs against their prevailing business model. But many realized that personalized treatments were inevitable and tried to find their way within a new paradigm.

    In cancer medicine, that new paradigm established a requirement of a companion diagnostic as a condition for approval of these new targeted therapies. However, it put such great pressure that the companion diagnostics that were approved often had been mostly or totally ineffective at identifying clinical responders to the various therapies. That is because genomics are far too limited in scope to encompass the vagaries and complexities of human cancer biology.

    However, Fromkin believed that the impetus for personalized medicine would come from payors, not drug firms. Insurers were paying for drugs that do not provide value, and have been desperate to eliminate the shotgun approach to cancner medicine. But how would drug companies respond when these tests show their drug to be highly effective, but only in 11% of the potential patient population? What can medicine offer patients whose test results suggest no medicine will help?

    A $1.5-billion-a-year drug is a blockbuster. Five $300-million drugs, taken together, do not add up. Unless the costs for developing a $300-million new chemical entity can be harmonized with the expected financial return, no one will develop such drugs. Charging significantly more for targeted therapies will work only to a point.

    Unfortunately, the introduction of these new drugs has not been accompanied by effective genetic predictive tests allowing for a rational and economical use of the drugs. Pharmacogenetics is not going to transform the market any time soon. However, given the technical and conceptual advantages of Oncologic In Vitro Chemoresponse Assays, together with their performance and the modest efficacy of therapy prediction based on analysis of genome expression, there is reason for a renewal in the interest for these pre-tests for optimized use of medical treatment of malignant disease.

    Merrill asked if I’ve been following the Potti scandal at Duke? Oh Yeah!

    http://cancerfocus.org/forum/showthread.php?t=3174

  3. I don’t doubt that a lot of excess is due to corruption, but I think there is more to this than just corruption.

    It is human nature to try and survive anything. We use words like “fight” and “battle” when describing reaction to disease on both a conscious level and a biological level (white cells are fighting foreign organisms, he lost the battle with cancer, etc.)
    Most cultures respect and prize those who fight to the bitter end, those who go down swinging, those who leave it all on the field, etc. The opposite is giving up, cowardice, weakness. Accepting one’s fate is not very American. Yankee ingenuity and winning against all odds and going where no man has gone before and the sky is the limit and it’s not over until it’s over and hope springs eternal, is what defines us as a nation.

    The other problem is that all these recommendations are fraught with words like “highly unlikely” and never 100% certainty. People buy lottery tickets where the chance of winning is practically zero, but not quite. If there is a 1% (1 in 100) chance to win, and there always is, people want to take their chances, because even if there is 1 in 100 chance to win a battle or a game, the only honorable and brave thing to do is walk onto that field and do the best you can do. There is nothing in our national ethos singing praise for those who chose comfort over struggle.

    The advances in medical science, from the days when people were bled and purged to death, to the days where one can get a replacement for his very heart, and the decrease in blind religious belief, have made it harder for people to accept God’s will when “confronted” by disease, at least not before they “tried everything”.

    It is against this cultural background that people are now told that doing what was considered the right thing all through the ages, costs too much. It just doesn’t compute.
    It may be infinitely easier to convince pharmaceutical companies to reduce the levels at which they exploit despair and hope.

  4. Barry Carol says:

    People buy lottery tickets where the chance of winning is practically zero, but not quite.

    Ah, but they do it with their own money, Margalit. That’s the key difference. How much should I as a taxpayer have to pay for futile care that someone else wants to access it because they want to keep fighting against all odds? When it comes to end of life care, I think the terms, “fight” and “give up” should be banished from the lexicon. If people want to spend their own money, though, that’s their prerogative.

    As for the expensive cancer drugs, suppose a particularly greedy drug company decides to price a new drug at $1 million per month and it extends life (with low quality) for a month or two. Should Medicare (taxpayers) have to pay for it just because the FDA approved it? I say no. The best way to push back against drug companies is to refuse to pay for drugs that don’t meet reasonable QALY metrics. The UK’s NICE approach makes sense and we should do it too, albeit it probably with a higher threshold than they use.

    Finally, regarding the WSJ, I’m a subscriber and I love the paper for its financial news but I’m often exasperated by its editorials, especially those related to healthcare. Refusing to pay for treatments that don’t work or cost far more than they’re worth is NOT RATIONING. Using elaborate protocols to decide who gets an organ transplant and who doesn’t when there are not enough organs to meet the demand IS RATIONING. There’s a huge difference.

    • Craig "Quack" Vickstrom, M.D. says:

      “Refusing to pay for treatments that don’t work or cost far more than they’re worth is NOT RATIONING.”

      Well, in a broad sense, yes it is. And this is bad because? We already ration medical care, we just ration by who is rich and who is poor. There is a more just way of doing it.

      • rbaer says:

        Re. what is rationing and what not, we will enter a near philosophical debate. We are already appraoching absurd situations in which patients in medical emergencies get sophisticated, costly inpatient care, and they just will be discharged to a life without follow up care, maybe the homeless shelter, thus mostly nixing the efforts of the hospitalization (I would of course argue that you need to address both poverty – that does not mean giving handouts – and acute medical illness, while libertarians would favor neither).

        I think Barry said it very well what needs to be done. Of course, if laws are made for medicare to do more of that, guess what the republicans are going to say? Start with death and ends with panels.

        And another point (that Barry made in a different context): patient expectations (culture) plays a role too. I cannot tell you how many complaints I have heard and read about patients who think (rarely correctly ) that they have been undertreated, until they switched docs and all kinds of test and treatments are done (while the previous doc “has given up”). There are some patients who feel that they are overtreated, but they seem in the minority, maybe because they react not verbally, but by staying away from the medical system. What do you think, Dr. Vickstrom?

        • Craig "Quack" Vickstrom, M.D. says:

          Patient expectations pay a huge role. I have argued that point several times here. Lack of follow-up also plays a huge role, which I also have argued for.

          The 800-pound gorilla in the health care debate is public health, or the lack thereof in this country. If we really wanted the most bang for our buck in medicine, we’d divert money away from acute care management towards obesity, diet, nutrition, sanitation, air quality, water quality, food purity, exercise, smoking cessation, recreational dug use, safer sex, contraception, and alcoholism. But I don’t think that will ever happen. We Americans are just too damn stupid. Public health is really where it’s at, folks.

        • Nate Ogden says:

          ” Of course, if laws are made for medicare to do more of that, guess what the republicans are going to say? Start with death and ends with panels.”

          Rbaer how about you and your liberal friends actually propose a bill even slightly similar to that befoire you go projecting republican answers? Republicans aren’t proposed to rationing they are opposed to the opaque and political manner in which the liberals want to do it.

          You hypocrits on the left are great at twisting facts that way. The right wasn’t opposed to helping the 13% of seniors that needed help with medical bills in 1964, they were opposed to Medicare which created a huge government program destined to fail that didn’t even address the problem it was supposedly crated to solve. Your type, along with help from the media, did a great job of portraying it as opposition to seniors.

          The right doesn’t oppose rationing, they oppose the idiotic ways the left wants to do it, there is a difference, if you care about honesty.

          • rbaer says:

            Sure, Nate. Honesty and ideology-free expertise based on science, that is what the GOP is all about these days.

  5. Bob Hertz says:

    In many other countries, the practice of charging helpless patients “whatever the market witll bear” for drugs is viewed as something barbaric, virtually cirminal.

    We need a kind of Hugo Chavez of health care, who will regulate drug prices with an absolutely clear conscience. A Pharmacy Price Review Board could be established to set maximum prices on any drug with no substitutes.

    The price would be set at the real cost of production plus 20%. The research would be considered a sunk cost, to be covered by all future sales.(this is how most companies operate in the real economy all the time.)

    If a drug company refused to sell for the maximum price, some patients would die. The executives of that company would be treated to full-page exposes for their greed. The families of the patients would probably find a way to sue the companies. Messy developments, but necessary ones.

    If this sounds like the commercial equivalent war, that’s because it is.

    Bob Hertz
    The Health Care Crusade

    • Nate Ogden says:

      “The price would be set at the real cost of production plus 20%. ”

      Bob this has been tried for decades and was a total failure every time, cost plus does not work, period. If you want some examples look how bad it was when medicare intermediaries where paid cost plus.

  6. “I think the terms, “fight” and “give up” should be banished from the lexicon.”

    Barry, I was just pointing out that what you are envisioning is an almost 180 degrees change in the culture of hundreds of millions of people. This is not something that can be done at short notice. You cannot legislate culture.
    So if we really want a pragmatic solution, perhaps we ought to look elsewhere for the short term. There is no support on either side of the political spectrum, in any segment of the population, for this type of change. Yes, this type of rationing or not rationing may indeed provide the biggest savings, but it is not politically feasible. I suggest we look at the other, smaller but much lower, hanging fruit.

  7. Gary Lampman says:

    Cancer for the most part can only be treated and often returns because treating Patients are more profitable than finding a cure! Chemical Therapy that mearly spreads cancer and a industry that rivals in snake oils and pills that manages to extend life and make patients sicker. The Onocologist is doctor Death.
    The cost of cancer care is so high because doctors play the gambet on tests and procedures to draw out more cash. Then when the patient Dies the Survivors are entrusted to pay.
    The simply way is to put the person down like vets have done with animals. Then the Docs,Hospitals and Pharma would not make a dime off cancers. Cheaper on families and No extreme Costs to the taxpayer. Remember, If your Republican to DIE Quickly!!!!!!!!!

  8. Excellent Merrill!

    Yes-Of course we need ethical and compassionate rationing.

    And we need ethical, fair and compassionate interdisciplinary “death with dignity panels”

    Finally the professional oncology community, in particular, needs a megadose of humility.

  9. Barry Carol says:

    From a patient’s perspective, I don’t think it’s too much to ask of oncologists to do the following: (1) Provide an honest assessment of the disease stage, estimated range of survival time including the mean and median, and treatment options, (2) Fully explain the likely side effects that come with each treatment option as well as the probable impact on quality of life so the patient fully understands what he/she is signing up for, (3) Be willing to work with palliative care and/or hospice specialists if that’s what the patient wants, (4) Don’t offer false hope and (5) Don’t view it as a personal failure when the patient dies.

  10. The financial costs of cancer care are a burden to people diagnosed with cancer, their families, and society as a whole. National cancer care expenditures have been steadily increasing in the United States. Cancer care accounted for an estimated $104.1 billion in medical care expenditures in the United States in 2006. In the near future, cancer costs may increase at a faster rate than overall medical expenditures.

  11. Barry Carol says:

    “and would you also agree Barry that if after all these steps the fully informed patient decides to “go for it”, we as a society will assume the costs?”

    Margalit –

    Not necessarily. I’ve said previously that I don’t think we should pay for expensive cancer drugs that cannot meet a reasonable QALY metric standard. If patients want to spend their own money for a non-covered drug, that, of course, is fine by me.

    The second issue is the age of the patient. If it’s a child or a relatively young adult, it’s easier to justify a full court press. However, the vast majority of cancers strike the elderly. If someone has already lived a normal lifespan and then some, I don’t think it’s reasonable to expect taxpayers to fund a large expenditure of resources for a small probability of a successful outcome.

    I would like to know more about how oncologists in other countries deal with elderly patients who have late stage cancer. Do they go through the list of possible options no matter how small the likelihood of success? Or, do they say there’s nothing more we can do for you aside from comfort care, palliative care or hospice care?

    I don’t know about you but I’m already paying 35%-40% of my gross income in federal, state and local taxes and that excludes the employer’s share of FICA taxes which I pay in the form of lower wages than would otherwise be paid, as well as corporate income and property taxes which are built into the price of the goods and services I buy. We have lots of unmet needs from infrastructure modernization to education. Expensive, largely futile end of life care, especially for people who have already lived a normal life span, is wasteful. If they want to fight to the bitter end at high cost, taxpayers should not be obligated to pay for it. I’m willing to pay somewhat more in taxes to deal with the federal debt and deficit but not for futile end of life care for the elderly that my wife and I neither want nor expect for ourselves.

    • Craig "Quack" Vickstrom, M.D. says:

      Maybe we can talk about this as a society, after we dismantle our foreign military bases and bring all our troops home. Let our corporations hire their own private military to protect their overseas assets.

      • Nate Ogden says:

        Next time 1 million poor africans are lined up for slaughter your ok with us just staying home Craig? Not all wars are for corporate interest, some of us take issue with dictators who kill hundreds of thousands of people, the same dictators the left tends to embrace and the NYT gushes over. See Sean Penns phonebook for examples

        • Craig "Quack" Vickstrom, M.D. says:

          Of course I’m not OK with it. But the USA should be a republic, not an empire. We can certainly do our part and be good citizens of the world without building military bases in other countries. As for dictators and violators of human rights (many of whom our governments supports), the UN and the ICC are the proper venues for dealing with that. Also, all this unilateral global military intervention is expensive. Time to take care of our own people first.

          • Nate Ogden says:

            “We can certainly do our part and be good citizens of the world without building military bases in other countries.”

            Great sound bite now lets look at reality, the same thing that tripped up Obama and all his promises.

            Without a base in the DMZ how would you propose keeping North Korea out of South Korea, if we hadn’t been there we would only have one Korea today and it would be communist.

            Our bases in Europe after WWII helped slow the spread of communism, something I am sure you are quit sad about. I wonder if your greater objection to our presence outside of the US isn’t the fact we act as a counter weigh to the socialism and communism you would prefer?

            ” As for dictators and violators of human rights (many of whom our governments supports), the UN and the ICC are the proper venues for dealing with that. ”

            By electing them all to the council, that’s the solution? Which dictator has the UNHRC ever successfully dealt with?

          • Nate Ogden says:

            ” all this unilateral global military intervention is expensive. Time to take care of our own people first.”

            missed this, we already have the fatest poor, biggest houses, most rooms, most TVs, on and on, its time for Americans to take care of themselves.

          • Poverty is a relative term.

            “By necessaries I understand, not only the commodities
            which are indispensably necessary for the support of
            life, but whatever the custom of the country renders
            it indecent for creditable people, even of the lowest
            order, to be without. A linen shirt, for example, is,
            strictly speaking, not a necessary of life. … But in the
            present times, through the greater part of Europe, a
            creditable day-labourer would be ashamed to appear
            in public without a linen shirt … Custom, in the same
            manner, has rendered leather shoes a necessary of life
            in England. The poorest creditable person of either sex
            would be ashamed to appear in public without them.
            … Under necessaries, therefore, I comprehend, not
            only those things which nature, but those things which
            the established rules of decency have rendered
            necessary to the lowest rank of people.”
            Adam Smith

            In the context of this thread, we should also explore if health care falls under “necessaries”. I have a funny feeling that, the woefully misunderstood, Mr. Free Market would have responded in the affirmative.

          • rbaer says:

            Nate wrote: “we already have the fatest poor, biggest houses, most rooms, most TVs, on and on, its time for Americans to take care of themselves”

            “biggest houses, most rooms” – did you ever notice that space is a cheap resource in the US, but scarce in densely populated Europe and Japan?
            “fattest” – rather a reflexion of US cultural and dietary factors. In developed nations, calory deprivation is not a problem, and calories galore do not compensate for a deficient diet.
            “most TVs” – the US is the only country where families put TVs in every room including the walk in closets, and yes, US units have more rooms. Very easy and cheap to get one used, and it’s a durable good (similar with cars, it’s especially cheap to maintain a car in the US). If you think that a TV or two indicates material security, one has to question your priorities.

          • Nate Ogden says:

            ” If you think that a TV or two indicates material security, one has to question your priorities.”

            If you think our poor having to forgo a 7th TV for their bathroom so we can keep some troops overseas to prevent Rwandans from being massacred by the tens of thousands is unacceptable then we need to discuss your morality.

            We spend more than we should to subsidize our poor, far more. Much of that money is wasted and spent inefficiently so the results are poor but it is not a lack of spending. We also get very little back from those we subsidize which keeps them in their situation. To say we can’t afford to spend a few billion to save, in this case really save as in life or death, while we waste so many billion more on ineffective welfare programs is ridiculous.

        • rbaer says:

          You are fantasizing about the number of TVs and the number of “rooms” in poor peoples homes. You are fantasizing about welfare expenses, unless you mean medicare. You also seem to indicate that the US is doing to little in terms of military intervention … nothing was done by the US in Rwanda. What has been done by the US has to do with perceived geopolitical interests and resources, enough humanitarian crises have passed without intervention. Let me ask you, Nate, do you think that the military endeavors over the last decade has been well invested money? It’s a “health care blog”, but your priorities and perspectives on how to spend money matter.

          • Nate Ogden says:

            ” the number of “rooms” in poor peoples homes.”

            I never gave a number how do you know I was fantasizing? Thats right you project everything anyways so what I was really thinking doesn’t matter becuase you will just make it up for me anyways to fit your argument.

            Just read an article about food stamps and how the cost is blowing up, was that a fantasy, did I imagine the numbers the USDA cited? I wish it was true, at that growth rate Liberals will be wanting to socialize food distribution by the end of the year. 14% on food stamps, thats going to pass uninsured in no time.

            Wouldn’t Medicaid be a welfare expense not Medicare????

            “You also seem to indicate that the US is doing to little in terms of military intervention ”

            Without a doubt, I can think of a dozen countries where populations are being abused that the international community, meaning the US since no one else really cares about this stuff, should be doing something. I have a real problem watching masses of people being slaughtered. After Rawanda when the world said never again, that should have meant something, sadly it did not. Just beciuase the rest of the world doesn’t want to stand up for the oppresed doesn’t mean we can’t.

            “do you think that the military endeavors over the last decade has been well invested money?”

            Where they good investments, yes without question, where they invested well, no, for the most part like all wars they were done politically which never leads to a good outcome. If your going to fight a war you go into it to win and win as quick as possible, if your checking public opinion polls and measuring international support you have already lost.

            rbaer, how do you feel about leaving a mass murder like Sadam in power? With close to 1 million deaths on his hands where you ok with him sticking around another 20-30 years?

          • Saddam? You mean the guy that we supplied with weapons of all sorts while he was fighting Iran? Weapons which he used internally and externally
            Funny how he became a menace to society when he started threatening our enlightened humanitarian friends in the Saudi peninsula, which just happens to be sitting on this huge barrel of oil…..

          • Nate Ogden says:

            As a card carrying flaming liberal hopefully you can help me with this argument. I never understood what liberals meant/mean when they talk about Saddam’s oil and how we invaded for the oil etc. I have a pretty good understanding of the commodities market and the flow of oil between nations. For the life of me I can’t figure out what Saddam’s oil has to do with anything. It was barely measurable how much their oil contributed to our supplies. It wouldn’t effect us one way or the other if they pumped or didn’t pump.

            Now if Venesula or Canada started getting a little upidty that would be a different story. If you hear us invading either of them then its all about the oil.

            So as an enlightened liberal please explain your oil reference so I can put this great quandry to bed.

          • Mark Spohr says:

            My dear flaming Nate… you are short on facts again.
            Iraq has more oil than Kuwait, UAE, Libya, Nigeria, Venezuela, and Russia. Your “pretty good understanding of the oil market is, like your understanding of, for instance, the health care system or poverty in the US, pinhead size.
            We did arm Saddam (he was our BFF and Dick Cheney visited personally) and he ended up exterminating hundreds of thousands of his people and Iranians (as well as Kuwaitis).
            The US realized even before WWII that control of Middle East oil was essential to world domination and that is why we keep dictators in power and invade when they get out of line.

          • Nate Ogden says:

            Hi Mark…….um can I make a suggestion?

            Please reread what I said then let me know if you would like me to maybe accept an apology or something.

            ” It was barely measurable how much their oil contributed to our supplies.”

            FYI Their = Iraq and our = America’s

            “Iraq has more oil than Kuwait, UAE, Libya, Nigeria, Venezuela, and Russia.”

            http://www.eia.gov/dnav/pet/pet_move_impcus_a2_nus_ep00_im0_mbbl_m.htm

            #1 Canada
            #2 Mexico
            #3 Saudia Arabia
            #4 Venesuela
            #14 Iraq

            What were you saying about my facts? The amounbt of Oil the US gets from Iraq is a rounding error.

          • Nate, Saddam’s move into Kuwait and the threat on Saudi Arabia would have destabilized the entire global oil supply. Not to mention that the paragons of human rights, and still our best friends ever, the Saudis. had a dog in that fight ….. so we obliged.
            I’m not contending that we should have sat still and watched Kuwait burn and Saudi Arabia burn after that, and the UAE burn too, but let’s just not call it human rights and/or weapons of mass destruction and/or imaginary terrorists under rocks. Call it what it is.

          • Nate Ogden says:

            “Nate, Saddam’s move into Kuwait and the threat on Saudi Arabia would have destabilized the entire global oil supply.”

            Inspite of liberal attempts to completly get rid of it 40% of our oil is domestic and another 30%? is from Canada. If Bush had got antsy and nuked the entire middle east this would not have been destabilized, I think the supply from Mexico would also have been pretty secure. Thats sort of the misnomer here, there is no global oil supply, for numerous reasons oil has some pretty specific flows. Its not like we could or would suddenly source our oil from country X instead of Y if it was $1 a barrell cheaper.

            ” imaginary terrorists under rocks”

            “We now know that during the years before 9/11/01 and the 2003 U.S. invasion of Iraq, over 8,000 terrorists were trained inside Iraq by the Iraqi military. ”

            “Since the invasion, materials captured, translated, and analyzed have only added further evidence. Smith reports, “Intelligence gathered since the U.S. invasion indicates that as early as the late 1990’s, Iraq’s Unit 999 (a special branch of the old regime’s army) was directly involved in the training of foreign terrorists inside Iraq. Intelligence about U.S. and other Western forces was shared between operatives of the Iraqi intelligence services and al-Qaida. And foreign terrorists operating in the region (outside of Iraq) who needed medical attention or other support received it once inside Iraqi borders.”

            Secret terrorist training camps in Samarra, Ramadi, and Salman Pak — all inside Iraq — were directed by elite Iraqi military units. At Salman Pak, a facility south of Baghdad, a number of videos, computer disks, documents, and other materials, including explicitly Jihadist propaganda. revealed terrorist training footage, where the targets were clearly Americans, and notes and communications (since translated into English) which document the cooperation between the Baathist regime and various terrorist groups.

            Sargat – an enormously significant international terrorist training camp in northeastern Iraq near the Iranian border — was run by Ansar al Islam, and based on information from the U.S. Army special forces operators who led the attack, it is indeed “more than plausible” that al-Qaida members trained there. ”

            What is imaginary about that Margalit?

            What is it your calling it? It seems every time I challenge you the name changes. I’ll be clear for you, it was WMD, Terrorist, and his aggresion along with non compliance of the UN Resolutions. It was not in any way oil.

          • There are terrorist camps all over the Middle East. Why not invade Syria, Libya, Iran or whatever? Besides, I thought this was about human rights, no? You can easily invade half the globe on account of human rights, but we don’t.

            Disturbing the global oil market would disturb global commerce and in turn American economy. You don’t have to actually buy oil from them to be severely affected. There was a good reason to initially turn on our former ally, Saddam, and kick him out of Kuwait. Unfortunately, we never finished what we started.
            There was no compelling reason for the second intervention.

          • Mark Spohr says:

            My dear Nate,
            It’s clear that you also lack an understanding of basic trade principles. Although not much Iraq oil reaches the US, oil is “fungible” (look it up if you don’t understand the meaning of the word). Even when the US imported little oil from the Middle East, we understood the strategic importance of the oil and needed to control it. Iraq reserves are #4 in the world and are vital to US control of world oil supply and that is why we went to war.
            If you believe that Iraq oil is not important to our control of the world and the profits of US oil companies, then you are truly naive.

          • Nate Ogden says:

            “There are terrorist camps all over the Middle East. Why not invade ……, Libya,”

            I believe that is being done now no? You can’t fight them all at once. Are you saying terrorist should not be attacked? We should respect their right to be terrorist and let them attack us? Its not just in the ME, South America and more then enough state sponsors as well and we spend millions and even foots on the ground fighting them as well.

            ” oil is “fungible”

            ouch, sorry to make you look stupid again but no oil is not fungible. Different processing plants are built to process different types of oil, do you know there are different types of oil? Our processing plants in Texas can’t just take any oil withour substantial modification.

            If Iran is not overthrown from within they will be invaded within the next few years. Hopefully that one will collapse from within.

            “You can easily invade half the globe on account of human rights, but we don’t.”

            True but how often do we act shocked about what happened and swear that we will never let it happen again? I don’t know where the line is but I assume there is some point where we can no longer pretend its happening and are forced to take action. How many people does a government need to murder before you want to take action? Saddam was near the top body count wise.

            “There was no compelling reason for the second intervention.”

            A number of UN Resolutions and 30? Other nations disagree with you. You might disagree but its a little disengenous to claim there was no compelling reason, this is another example of your liberal deficency. What if we didn’t take him out what would you expect to happen? Did you want another 10 years of oil for food? Did you want our pilots shot at till a few of them were killed over the no fly zone? Or did you want to drop the no fly zone and allow the kurds to be killed. Have you even given any thought to the alternative or did you stop after the sound bite? The second invasion was to fix the idiotic way the first one ended. There was no alternative but to overthrow him.

            “Disturbing the global oil market would disturb global commerce and in turn American economy”

            I think your falsely equating all distrubtion with being bad. We have termendous domestic supplies available and don’t use them. Lets say Iraiq’s oil gets pinched, we could increase domestic production which would generate tons of jobs and keep billions in our economy and thus substantially increase our GDP and Tax base. Does any of that sound bad to you? China’s cost of production and that of Europe could increase raising the cost of imports making our goods more competitive, does that sound bad? Iran’s access to refined gas could be limited upsetting the citizens and pushing them to overthrow the mullahs, does that sound bad?

            Mark, I’m just totally confused now. You totally butcher a post and get your brain handed to you, question my facts when the problem is your inability to read, and you follow it up with another claim saying what I do and don’t understand? The only person that appears to have problems understanding is you, get your game together kid.

            “Because the different oilfields of the world produce oil with different combinations of hydrocarbon compounds, and with varying levels of other contaminants, such as, for example, sulfur, it is not always easy to switch the oil supply coming into a refinery from one field to that from another. The EIA has plotted the increase in sulfur content coming into US refineries. As the crude becomes heavier and contains higher sulfur content, so the refining process becomes more complex and expensive. ”

            “For many years, for example, the heavy, high sulfur, crudes produced in Venezuela were shipped to refineries in the United States that were designed to refine the oil to the desired products. Other refineries, geared to refining lighter sweeter (i.e. lower sulfur) crudes cannot accept very much of the Venezuelan oil and blend it into their process streams, since even to get to an intermediate crude they would need to include a higher quality (and more expensive) lighter crude in the blend. Thus when there was a strike in Venezuela in 2002, and the world lost 3 mbd of oil production, there was only a limited flexibility in the way that the affected refineries in the United States were able to resolve their supply shortfall. ”

            “There are certain oilfields where the contamination of the crude is such that special refineries are needed to process the oil. The most outstanding of these is the oilfield at Manifa in Saudi Arabia, ”

            hum…doesn’t sound very fungible to me mark…….anything else you would like me to teach you?

          • Nate Ogden says:

            margalit some of marks responce jumped in the middle of yours, sorry

    • Mark Spohr says:

      “do they say there’s nothing more we can do for you aside from comfort care, palliative care or hospice care?”

      Sometimes the honest answer is this… “the best we can do for you is to make you comfortable at home since you have an incurable disease and our treatment will only make you miserable for the few remaining months of your life.”

      I know three friends in the last year who would have had a much higher quality “end of life” if their oncologists had been honest with them.

  12. Barry,
    “Or, do they say there’s nothing more we can do for you aside from comfort care, palliative care or hospice care?”

    I would suggest that the current practice, if oncologists are erring on the side of hope, may be for the financial benefit of certain stakeholders. The equally dishonest alternative above is for the financial benefit of a different set of stakeholders. Either way it’s solely about money and not about the patient as a person (I don’t want to use the term patient-centered since it rings hollow to me by now).
    I appreciate you not wanting to fund things you may not wish to use, but I fund those type of things every day. Not sure we can pick and choose individually.

  13. Barry Carol says:

    Mark –

    Thanks for that comment. I suspect that the oncologists who treated your friends were guilty primarily of offering false hope as opposed to a desire to make more money. To deal with the payment issue pushing oncologists toward more aggressive treatment rather than less, United is experimenting with a bundled payment approach. Oncologists can still treat more aggressively than the bundled payment calls for in certain cases if they think it’s appropriate, but they will only be reimbursed for their incremental cost and will not make any profit from the extra treatment. Some oncologists, as I understand it, also won’t even let a palliative care specialist anywhere near their patients. That’s unfortunate too.

    Recently, there was a study at Harvard involving patients with late stage lung cancer, I believe. Half the patients received aggressive treatment while the other half got palliative care. Incredibly, the palliative care group actually lived somewhat longer and with higher quality of life to boot. The mentality among patients that more care is always better care and more expensive care is better care needs to change as well.

    • Craig "Quack" Vickstrom, M.D. says:

      “The mentality among patients that more care is always better care and more expensive care is better care needs to change as well.”

      THAT mentality has to change everywhere, with everyone.

      • rbaer says:

        Not with everyone. As I mentioned above, there are patients who want to use drugs and surgery as little as possible, some because of general preferences, others explicitely due to cost considerations.

        However, docs are often in a bind, as patients and families sometimes become quite irritated when you suggest doing less (and when one says: test x would very unlikely change management, they counter: yes, but it is important to know). And, I would venture, 90% of practicing docs, myself included, will tell you that defensive medicine plays a role.

        Ideally, docs and patients would abide to the few applicable rules of evidence based medicine, and extra tests/procedures simply would not be covered (unless via selfpay/supplemental insurance). Unfortunately, a large part of patients (and docs alike) are not ready to give up irrational overutilization (not to mention rational overutilization, driven by financial interests).

        • Craig "Quack" Vickstrom, M.D. says:

          True, true. I would say defensive medicine plays a BIG role, but that is own circumstance. YMMV.

  14. Craig "Quack" Vickstrom, M.D. says:

    This article has brought the real issue of health care to the fore: the recognition that the resources of even the USA are not infinite, and the argument over how to allocate these scarce resources.

    We have the faction that argues vehemently against subsidizing our own people, but argues strenuously for subsidizing other people. Then we have the faction that argues for subsidizing our own people, but against (large-scale) subsidizing other people. I can only wonder how this is going to play out in the years to come.

    • Nate Ogden says:

      if your dishonest framing of the issue is any indication then very polarizing.

      “We have the faction that argues vehemently against subsidizing our own people”

      Who has said we should end all subsidies and assistance, no one is making this argument. They are arguing the extent to which we assist them and the fact we often ask or expect nothing in return.

      “Then we have the faction that argues for subsidizing our own people, but against (large-scale) subsidizing other people.”

      This is an accurate portrayal. I can wager which one you see yourself as, the second one with the nuanced and accurate summary, the one without the harsh edges.

  15. John Ballard says:

    Nate Ogden is amazing.
    He has a reply for nearly every comment and he’s always right.
    (Still looking, but I have yet to read an unqualified endorsement from him. Sadly nobody gets anything exactly right. )

  16. Nate Ogden says:

    John, I probably shouldn’t give this secert away but if you promise not to tell anyone I’ll let you in on it;

    “he’s always right.”

    It’s not that I am always right, if I don’t know something I don’t go posting about it on the internet though. If I am going to comment about something I first know what I am talking about or I don’t say anything. That might give the allusion I am always right but it doesn’t address the countless things I have no clue about.

    If there are discussions about the correct treatment for this or that, or talk about EMRs for example you won’t hear from me, unless its to ask a question.

    ” I have yet to read an unqualified endorsement from him.”

    My employees complain about the lack of positive affirmation as well. I just never got it, people that comment good post, or I agree, it just always seemed like a waste to me. I do occasionally complement Margalit of some of her ideas. Barry I often agree with. There out there.

  17. John Ballard says:

    Mm-hmm…
    Modest, too.

    • Mark Spohr says:

      Nate is right even when he is wrong. He will go off on a nasty rant and leave you confused about how to even start a response. It’s the perfect way to end a discussion. I try not to respond to him but he is such a rude flaming diehard that it is hard to not challenge his absurd statements. However, it always ends badly so best to avoid him if you can.

  18. Nate Ogden says:

    “He will go off on a nasty rant”

    “It’s clear that you also lack an understanding of basic trade principles.”

    “My dear flaming Nate”

    “like your understanding of, for instance, the health care system or poverty in the US, pinhead size.”

    “he is such a rude flaming diehard”

    Project much Mark?

    “Nate is right even when he is wrong.”

    Never heard back from you on how fungible oil is, is your new argument that every oil processor building refineries doesn’t know what they are talking about either?

  19. John Ballard says:

    When our kids were growing up we called it “The Last Word” game. Whoever gets the last word wind.
    “Did not.”
    “Sure did!”
    “Didn’t.”
    “Did.”
    “Didn’t.”
    “Did.”
    “Did not.”
    “Did.”

    You get the idea. Something like “Mama, he’s staring at me. Make him stop looking at me!”

  20. Robin Monson says:

    I agree witih Barry Carol’s remark May 30, 2011. For the most part, physicians are trained to heal, not to provide palliative care. By providing a complete explanation of the disease process, estimated life expectancy, side effects of treatment modalities and any benefits that may be achieved, patients may be in a better position to make a decision. In my experience, life expectancy is usually not discussed with the patient if the patient does not ask this question. I do have a problem with placing individual choices in the hands of physicians regarding options available. Where does the line get drawn? Are we going to decide that patients of a certain elderly age should not be entitled to high cost life prolonging treatments such as dialysis? What a scary thought.

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