Perspectives on Health Care Reform: What’s to Be Done About Cost Containment?

Since continuing technological advancements are going to add to rising costs (dialysis, for example, with more "baby boomers" coming of Medicare age), one has to wonder what the something is that "has to give" in the future. We will be seeing patients with psoriasis, renal failure, and advanced cancer-and considering the high costs of pharmaceuticals for those who can and those who cannot afford to take them. When should we begin to determine how much is more life worth? Since it is apparent that these rising costs cannot be sustained indefinitely, will we ration, will we stop and draw the line for some of these miracle drugs and the people who want to take them?

Pravin Shah said:
Expectation and cost need to be tempered with affordability and ultimate return in terms of gains in life expectancy, real quality of life improvement, and out of pocket expense.

Dorothy Talotta said:
I think it would be helpful if we looked to other countries for ideas on how to solve our health care issues. In the U.S., we spend a great deal of money on the salaries of C.E.O.'s of insurance companies and dividends to insurance company stockholders. This is money that we all pay in health insurance premiums. If we did not have the system of for-profit, private insurance companies that we have here, that money could all go towards health care. . . . Countries such as Canada, Great Britain, and others spend far less on health care than the U.S. does and yet their measures of health care quality such as life expectancy, infant mortality rate, etc. equal or, in some cases, exceed ours. While their systems might not translate seamlessly to the U.S., I believe we can certainly look towards the systems in place in these countries to help us in our situation.

John Dente said:
Everyone must realize that America is no longer a wealthy nation, and if the dollar wasn't the reserve currency this nation would be bankrupt. However, even with the dollar as reserve currency, the national debt cannot be sustained indefinitely. Along with this the population is growing older as the medical technology becomes more expensive, so the application of these technologies for diagnosis and treatment will have to be looked at more closely. An example is Provenge, a new vaccine, called a vaccine, because it helps stimulate the body's immmune response to prostate cancer cells, and prolongs survival by 4 months, costs about $93,000. Whether it is worth it or not is subjective; what is not subjective is that someone has to pay for it, and can anyone afford it.

Dr Rutecki replies:
Thanks to my 3 colleagues for some very insightful comments. Their suggestions are right on target. First, Great Britain already factors in quality and duration of survival after approving a specific treatment/pharmaceutical. They have an agency called the National Institute for Health & Clinical Excellence (NICE). People have suggested that we do the same (JAMA. 2008;337:137). NICE has decided some high-ticket items (eg, bevacizumab for cancer) don't provide enough bang for the prohibitive buck. Second, this example not only verifies wisdom can emanate from other countries, but Holland's healthcare reform also jettisoned for profit approaches to healthcare. Finally, there are more sticker shocks coming, like the prostate cancer vacccine that may be as expensive and unfortunately as efficacious (a pun) as bevacizumab or cetuximab.

For all the comments and Dr Rutecki's replies, go to the Primary Care Matters BlogJoin the conversation!