Posted on 07/08/2009 3:29:41 AM PDT by M. Dodge Thomas
... let’s talk about prostate cancer. Right now, men with the most common form can choose from at least five different courses of treatment... Some doctors swear by one treatment, others by another. But no one really knows which is best. Rigorous research has been scant. Above all, no serious study has found that the high-technology treatments do better at keeping men healthy and alive.
“No therapy has been shown superior to another,” an analysis by the RAND Corporation found. Dr. Michael Rawlins, the chairman of a British medical research institute, told me, “We’re not sure how good any of these treatments are.” When I asked Dr. Daniella Perlroth of Stanford University, who has studied the data, what she would recommend to a family member, she paused. Then she said, “Watchful waiting.”
But if the treatments have roughly similar benefits, they have very different prices. Watchful waiting costs just a few thousand dollars... Surgery to remove the prostate gland costs about $23,000. A targeted form of radiation, known as I.M.R.T., runs $50,000. Proton radiation therapy often exceeds $100,000.
Use of I.M.R.T. rose tenfold from 2002 to 2006.. A new proton treatment center will open Wednesday in Oklahoma City, and others are being planned in Chicago, South Florida and elsewhere. The country is paying at least several billion more dollars for prostate treatment than is medically justified — and the bill is rising rapidly.
You may never see this bill, but you’re paying it. It has raised your health insurance premiums and left your employer with less money to give you a decent raise. The cost of prostate cancer care is one small reason that some companies have stopped offering health insurance. It is also one reason that medical costs are on a pace to make the federal government insolvent...
(Excerpt) Read more at nytimes.com ...
As someone whose wife has had a cancer were you can get radically different medical opinions is the best course of treatment, I can personally attest that under current conditions it's often impossible to make "rational decisions" about which course of treatment is appropriate, the system is set up in such a way that there are strong incentives not analyze which treatments are objectively most effective, or to make that information available individual consumers of medical care.
With Socialized medicine, timely therapy will ONLY be
available for Congressmen and their families.
Seems the point is that cheap will win over better any time.
Sometimes cheap is better but not usually.
I have cancer and got the same opinion as to initial treatment from three docs. I read the literature and agreed. For recurrence, there is more of an art to treatment but I read the journals and know the stats on the different drugs.
I have thought an MD who would be a consultant to patients with cancer, read the lit, know about the trials, understand the treatment and pros and cons would be a good idea in times when there are differences.
But I do think good oncologists mostly agree in most cases. It is when the research is moving fast and different modes of treatment aren’t compared head to head that problems occur.
A hard time for a patient weighing choices.
My greatest concern with what's going on in Washington with socialized medicine, aka health care reform, is that treatment decisions will be taken away from future cancer patients by some nameless bureaucrat on the basis of cost control or medical necessity. This is the perfect example considering there are many ways to treat the same illness and each has its advantages and disadvantages based upon the individual needs of the patient. That is why it's imperative that the treatment decision stay with the patient and their Physician because they would have far better knowledge as to the proper course of action than a “one size fits all” solution from Washington.
“I” was fortunate enough to be able to select the form of chemo I received, AND it was very effective.
Still clean after 2 1/2 years.
This is absolutely not the case. There is massive research out there. Check the Johns Hopkins website, e.g. Every time DH, PC survivor, goes in, he is filling out surveys and questionnaires as is his physician. He made the decision on treatment based on doing lots of research provided by physician and website info.
NYT shilling for one payer system again - and doing so with a faulty premise.
Certainly, that's often when the problem is worst.
What a lot of posters here don't seem to be getting is that this is a problem irrespective of the system you select to pay for medical care; that unless any system of insurance - "public" or "private" - has infinite resources to pay for treatment, decisions have to be made about which treatments are cost effective enough so they will be covered, and the best decisions are based on reasonably good assessments of both costs and outcomes.
However, at the moment, most politicians on both the right and left are attempting to operate a fool's paradise were on the one hand we maintain that everyone is entitled to whatever medical care they decide they should receive for major conditions, while the same time we are are angry at being asked to pay the insurance premiums and taxes to provide it.
Under these conditions the biggest difference between "conservative" and "liberals" on the question is that conservatives understate or ignore the problems of access while fuming about cost, and the liberals understate or ignore the problems of cost and fume about access.
Unfortunately, this sort of denial is getting to be a luxury we can't afford, either in terms of the insurance premiums we pay for those covered privately or the taxes we pay to provide care for the uninsured and and the increase taxes we will soon be paying to cover Medicare shortfalls.
In this situation, it's very difficult to justify paying twice to four times four times the cost for alternative therapies on which we have no effectiveness data at all, except on a limited basis as needed provide data for clinical trials, otherwise we will be faced with the very real possibility that this money has been squandered rather than spend on increasing access to treatments of known efficacy or on additional research.
> This is absolutely not the case. There is massive research out there. Check the Johns Hopkins website, e.g. Every time DH, PC survivor, goes in, he is filling out surveys and questionnaires as is his physician. He made the decision on treatment based on doing lots of research provided by physician and website info.
The article probably would have been stronger if the author had left out the question of the efficacy of surgery vs. watchful waiting (though IMO this is not nearly as cut and dried a question as you seem to suppose, especially in the case of older men).
But that doesn't detract from the relevance of the main issue being raised in the article: the efficacy of very expensive therapies such as I.M.R.T. and Proton radiation therapy, in these cases we have made large infrastructure investments and are running up large treatment costs before initial studies have run long enough to produce reliable measures of efficacy.
> NYT shilling for one payer system again - and doing so with a faulty premise.
The problems of rapidly escalating costs based on providing expensive unproven therapies (and, I'd add, therapies which extend life only weeks or months at very high cost) are just as real for private as for public insurance programs.
IMO interest in HIFU (which may well turn out to be a superior technology for the treatment of many prostate cancers) is higher in other countries precisely because it's much less expensive, and other health care systems are miles ahead of us in paying attention to the cost-benefit ratio of such therapies.
If our attraction to a incentive system that favored highly profitable (because it's very expensive) "gold plated" medical technology was actually producing outcomes as superior as they are costly it might be more justified, however in many cases such as prostate cancer there is scant evidence that this is the case.
That's part of the problem this article addresses.
The problem is for instance there are about 15 second line treatments for recurrent OVCA. All are of similar effectiveness but each individual patients responds to one or another that others may not respond to. So if you say all are equally effective in a population, with cost effectiveness as the goal, then you cover the cheapest. And an individual person may only respond to one which is very expensive.
Plus what if as Obama stated, you don’t pay for meds unless you are getting a “cure”. There are few cures in cancer, most live for a long time with different lines of treatemtn and they say their life has good quality.
Who in hell is going to be presumptuous enought to say only three cheap meds will be approved and unless you are predicted to have a cure, it won’t be paid for.
Nobody would or should say that. So cost effectiveness is not a even partly complete science at this point and even if you knew for usre the cheapest treatments for a population,,those treatments may not work for you or your Mother or Father.
There is a glibness about discussing this like the issue is black or white and what it is is grey with human beings whose lives are on the line.
Contrary to all the hype about preventative care, mammography is set to be eliminated.
There is a glibness about discussing this like the issue is black or white and what it is is grey with human beings whose lives are on the line.
There's also a certain "glibness" in assuming the we can afford to pay for optimum outcomes for everyone... especially in a situation where we are doing far from an optimum job allocating results to produce reasonably good outcomes for most people.
It's pretty tough for a lot of people to accept, but we are always going to be "rationing" outcomes - always have, always will.
As a society we are extremely reluctant to talk about these choices, even as we make them we pretended life is "priceless", when in fact both private and public insurers find ways to put a price on human lives every day as part of their their normal business practice (for example, by declining to pay for "experimental treatments", or treatment provided outside of the provider's network).
So it's not that it doesn't happen, it's just we don't want to talk about it - we instead prefer the polite fiction that even if we have not achieved this goal today, that providing optimum outcomes to everyone is both a desirable and achievable goal.
And interestingly, for all our talk about personal autonomy and its importance in personal medical and financial decision-making, we work very hard at preventing people from actually making such choices.
And my strong suspicion is that if we did offer people such choices, a lot of people would end up making different ones there our preconceptions lead us to expect, that if for example if we offered Medicare patients with terminal cancers the option of accepting the $25,000 worth of expensive and essentially futile care to briefly extend their lives, or hand their surviving spouse a $25,000 check, I expect many people here would be quite surprised by the number who chose the latter.
However in such matters we prefer pious platitudes to frank discussion.
Your frankness is talking about rationing care for individuals, no matter how you frame it, that is what you are talking about.
One is free to pay top dollar for top insurance with choice and no gate keeping. That is what I do. ANd if one wishes one doesn’t have to do that or indeed have treattment.
I suspect your “coolness” and “frankness” is a cover for a lot of malice toward your fellow man.
I am thru discussing this with you,,the psychopathy of your argument, the malice of it makes me wonder who in hell I am talking to.
Lets end it.
You're talking to someone who along with his wife, made very substantial economic and career sacrifices to provide a decade of in-home care to his in-laws in order to honor a promise that we would do everything possible to allow them to remain in their own home as long as possible - who accompanied his in-laws to innumerable doctor visits, change their diapers, fed them from a spoon when they can no longer eat unassisted, traded shifts with his wife to provide nighttime care, spent countless hours negotiating the twists and turns of the medical system, and is one half of a couple who have been told by other members of my in-laws extended family that they regard us as "near saints" based on the sacrifices we made and the level of support we provided.
Your're talking to someone whose wife has had cancer (at the moment she is still with us).
You're talking to somebody who's found himself laying on a hospital gurney, knowing he might not see the next morning.
But you're also talking to somebody who is paying attention, realizes we don't have unlimited resources, that choices have to be made, and that those choices affect the quality of care available to myself, my wife, you and everyone else in this country, irrespective of the depth of financial resources available to pay for care.
You note that "One is free to pay top dollar for top insurance with choice and no gate keeping. That is what I do."
Did you build the hospitals and medical centers where receive your care?
Pay for the basic medical research that underlies many advances in medical care? (It's not economically feasible for private industry to fund most of this research.)
Pay the operating costs of the institutions which trained doctors and nurses who treated you?
All these things are heavily subsidized by you, me, and every other taxpayer - and without them it would not be possible for you to purchase high-quality medical care at any cost, irrespective of your ability to afford the best possible insurance, or even purchase unlimited care out of pocket.
It's convenient to think of people like myself as coldhearted monsters if you want an excuse not to acknowledge that the infrastructure that provides your medical care is heavily dependent on public subsidy, and that we don't have unlimited public resources to devote to medical care.
It's convenient to ignore the fact that the matter how great your personal resources, you cannot buy better medical care than exists -that if we spend vast amounts of money for treatments we do not know produce better outcomes than cheaper alternatives, that is money that is not being spent to develop better alternatives - and if those better alternatives do not exist, no matter how great your resources you receive worse medical care that if they did.
It's convenient to ignore that we already do a lot of "rationing" that controls the availability of medical care to everyone in our country - no matter how great your financial resources.
If you are involved in a catastrophic automobile accident on vacation in Taos, it does not matter what kind of care you can purchase in New York City, or Los Angeles, or Dallas - what matters is the quality of the care that's available in the critical first hour after the accident.
And if we sink $20B a year billion into extending the lives of individuals with advanced Alzheimer's disease, that's $20 billion a year that is not available to make sure there's more than one class I trauma center in all of New Mexico, with the result and that there is zero chance you will get to that center within the hour, even if a helicopter is available. (Except under ideal conditions, you are not even going to be able to get there from Santa Fe, the state capital).
One of the reasons conservatives are losing the battle to shape the direction of healthcare in this country is because we refuse to talk realistically about these things at all, while liberals - no matter how poorly or unrealistically they may reason when they discuss them - are willing to face that it's both true that without these subsidies we would have a third world medical system, and that choices have to be made about what we subsidized.
Meanwhile most of our conservative elected representatives stick their heads in the sand and simultaneously argue that have the best healthcare in the world while refusing to knowledge that this is the case largely because we are taxed to supply enormous public subsidies to pay for it - subsidies which in my view in many cases are being distributed on the basis of votes bought by contributions from special-interest groups both public and private, with the result that much of that money is spent in irrational and sometimes even counterproductive ways.
If my concerns are "psychopathy", what would you call the mental state of the participants in that process?
Here's an example of what I would hope would be a non-controversial example of improving the allocation of medical resources by improving the ability of individuals to make better informed decisions about end-of-life care:
http://www.sciencedaily.com/releases/2009/05/090528203743.htm
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