OP-ED

Vouchercare for Cancer

The health care cost debate takes place on two stages using two languages, one scientific, the other economic. The net result is a failure to communicate.

The scientific texts emanated over the weekend from the American Society of Clinical Oncology meeting in Chicago. Ongoing clinical trials showed that science has come up with new drugs that can reduce the incidence of breast cancer and prolong life for people with skin cancer. The former is an estrogen inhibitor that would have to be taken by tens of millions of older women to have a major impact on reducing the rate of breast cancer. The latter would only be given to a subset of the 68,000 new cases of melanoma each year, and would extend life from a few months to a few years for some of the 7,700 who die from the disease each year. Again, most of those people are older, although there are a number of younger people, especially young women, who disproportionately get advanced skin cancer.

For both groups, the cost to the health care system when these drugs are approved, as they inevitably will be, will be calculated in the billions. Medicare will pick up the lion’s share of the tab, since most of the patients in both groups will be over 65.

Now let’s step around the corner to stage two, where the debate in this morning’s papers (if you read the Washington Post and New York Times every day, as I do) is over Rep. Paul Ryan’s plan to turn Medicare into a voucher program. Paul Samuelson, the top economics columnist in the Post, essentially endorses the plan saying “under Ryan’s plan, incentive would shift. Medicare would no longer be an open ATM; the vouchers would limit total spending.” What he doesn’t say is that it would only limit total spending by government. It would require seniors to pick up a growing share of the bill, and limit their own purchasing of health care, either by purchasing plans that didn’t cover expensive end-of-life care, or simply denying themselves routine treatments to avoid co-pays and deductibles.

Paul Krugman properly attacks this as a radical shift of costs onto seniors (which it would be), and goes on to say:

Medicare has to get serious about cost control; it has to start saying no to expensive procedures with little or no medical benefits, it has to change the way it pays doctors and hospitals, and so on. And a number of reforms of that kind are, in fact, included in the Affordable Care Act. But with these changes it should be entirely possible to maintain a system that provides all older Americans with guaranteed essential health care.

That, of course, begs the question of what’s essential. Is a cancer prevention drug that cost $1,000 a year and will, if reimbursed by Medicare, cost billions annually to reduce the incidence of breast cancer from 14 per 1000 to 10 per 1000 “essential”? Is a drug that extends the life of a few thousand people an average of six months or so at a cost of $500 million a year “essential”?

America’s love affair with scientific medicine shows no sign of ending. Incremental improvements in cancer care and other advanced technologies are inevitable in the years ahead, since the government ($31 billion a year) and the private sector (over $50 billion a year) continue to make health R&D the nation’s number one priority when it comes to science (it’s 20 times greater than what we pour into energy R&D, for instance, even though a good argument could be made that man-made climate change due to excessive burning of fossil fuels poses the greatest planetary threat to human health).

Somebody in the not too distant future is going to be given the job of rationing this expensive health care (I’ve given up on even having a national or rational discussion about limiting the outrageous prices that the private sector charges for these treatments). Samuelson is right in his conclusion that “the only questions are when and on whose terms” this rationing will take place.

For my money, I’d rather have a government-appointed panel, chosen by our elected leaders, that has to submit its recommendations to Congress do it. The alternative is having an insurance company’s hidden panel make those decisions. Those decisions will be made without public oversight, and then announced to the world through the mechanism of price, with those who can’t afford the tariff being the ones who experience the rationing.

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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Ronald Lavine, D.C.Dr. Michael JamesNate OgdenBarry CarolDr. Rick Lippin Recent comment authors
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Ronald Lavine, D.C.
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So this week a man with low back and sciatic problems comes in to see me. I make treatment recommendations to attempt to improve the biomechanical function of his low back. But he also sees a spinal specialist who’s an MD. Within the blink of an eye he’s already had Xrays, MRI’s and CAT scans. I can understand that from a certain perspective, all of these tests are rational and represent the “responsible” practice of medicine. On the other hand, I help a lot of people. Not everyone. But a trial of therapy is also a “diagnostic test”, and in… Read more »

Nate Ogden
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Nate Ogden

” is that it is insurance coverage that you cannot lose. Unlike private sector insurance, Medicare does not depend on employment.” Actually you can lose it and people have lost it. Its dependent on politicians and could be taken away any day if there was a financial crisis or change in government. How many millions are going to lose their MA coverage, no one thought that would ever happen. What if they change the secondary payor rules again and you have no medicare if you have insurance through work? If you enroll in MA you lose your Traditional Medicare. What… Read more »

Nate Ogden
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Nate Ogden

” I can personally cite many, many examples of folks over 65 who are still working” What relavance does that have? How many working people with cancer do you know under age 65 who filed BK? I can’t even see what argument your trying to make? Wouldn’t none working people over 65 who would be collecting social security be proof that it is SS not Medicare that prevents BK. “many younger cancer patients come from two income families ” How many two income families filed BK after one member came down with cancer? Second paragraph from the write up; “”Patients… Read more »

Dr. Michael James
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Dr. Michael James

The huge difference that sets Medicare apart from all private insurance, and thereby differentiates its effect on income is that it is insurance coverage that you cannot lose. Unlike private sector insurance, Medicare does not depend on employment.

Nate Ogden
Guest
Nate Ogden

” The only exception to these findings were cancer patients over 65 years old. Why? Because they have Medicare.”

I have to call BS on this doctor. The reason it declines is because they have Social Security, Medicare has little to nothing to do with it. If you have serious cancer how are you working? If your not working how are you paying your bills? Once you start collecting SS you have income and thus the decline.

Dr. Michael James
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Dr. Michael James

Call it whatever you like, Mr. Ogden, I can personally cite many, many examples of folks over 65 who are still working (with or without serious health issues) – so Social Security is not the reason. In addition, as I’m sure you are aware, many younger cancer patients come from two income families – otherwise they would not have insurance or income – and the rate of bankruptcy would be even higher.

Dr. Michael James
Guest
Dr. Michael James

An interesting study that is especially germane to this discussion was recently presented at the American Society for Clinical Oncology meeting in Chicago. This study which examined bankruptcy rates among cancer patients was presented by Dr. Scott Ramsey of the Fred Hutchison Cancer Center. Cancer patients overall are twice as likely to file for bankruptcy as the general population. The bankruptcy rate increases the longer a cancer patient survives. The only exception to these findings were cancer patients over 65 years old. Why? Because they have Medicare. With ‘vouchercare’, this economic protection afforded to our seniors would be taken away.… Read more »

Nate Ogden
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Nate Ogden

“For my money, I’d rather have a government-appointed panel,” What would be different from this new government panel and the previous ones that have failed to control cost? We have had government panels going back 40+ years that are suppose to reign in Medicare Spending and have failed. How many decades of failure do you need to see before you start to wonder if government might not be capable? The other short coming in this argument is recognition that your still asking a disinterested third party to control cost, it doesn’t matter to this government panel what cost is or… Read more »

Barry Carol
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Barry Carol

This is one of the rare times I agree with Krugman when he says we need to learn how to say no to payment for expensive treatments for a marginal benefit. I would also be willing to trust the IPAB to take on this role. These are admittedly subjective and difficult calls but someone has to do it. People who contend that you can’t put a price on human life and those who want to fight to the very end should have their wishes respected and that someone else should pay for it are driving us toward bankruptcy. The only… Read more »

Dr. Rick Lippin
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Merrill- Thanks

Rationing is inevitable – It must be done ethically , fairly and with as much compassion as possible.

I agree that the government is MUCH better suited to lead on this than the private sector .

The goverment must lead on issues of the common good like at least providing BASIC health care for all US citizens. That is what civilized nations do.

Merrill- Also I personally think many patients are falling “out of love” with high-tech, high-cost medicine especially at the end of life