Demanding Value in Health Care

05/26/2011 02:44 pm ET | Updated Jul 26, 2011

Government decisions on medical policies are often emotionally charged and difficult to make. There are frequently well-meaning people and strong economic forces with competing interests on both sides of health issues. The present approach to these decisions -- avoiding confrontation and hoping things will somehow, miraculously, improve -- has not been the answer to our health care problems. Instead, political forces must be rallied and mechanisms established to promote scientifically based, compassionate, affordable medical plans of action. Hard choices need to be made and priorities determined or America will never get its health care system in order. But each time we decide a medical policy, a critical question that has been neglected up to now must be asked, "Is the care we are receiving worth the price we are paying?"

Health care is a product, much like many other essential things that we purchase, e.g., shelter, clothing, or food. When we buy a product or pay for a service we expect value. We expect it at the supermarket as we make choices that directly affect our well-being. We should similarly demand value as we decide how our health care dollars are spent. To do so, at first glance, might seem callous or uncaring since life is viewed as priceless. Yet insurance companies and our court systems routinely assign dollar amounts to injuries and loss of life; and other countries, with far better health care system than ours, consider cost when they settle on their health policies.

Value in health care is difficult to determine, far more so than the value of produce or canned goods at the grocery. Deciding medical value requires well-conducted studies, scientific expertise, and experience. It also requires a framework, in essence, a medical measuring stick with which to compare the scientific results from a particular medical policy against data from other similar treatments or tests. Certainly deciding the value of medical care is difficult, but it can be done.

The common measurement used in medical studies is termed Quality Adjusted Life Year (QALY). This is the total cost of testing and treatment in a population to allow one person to live one added year of quality life. For example, if the total cost of screening and treating a community for a targeted disease is $80,000, and two people live an extra year of life as a result of this medical policy, the cost for a QALY would be $80,000/2 or $40,000. Medical policies that cost $50,000 or less for a QALY are considered cost-effective. The exact price of a QALY may be debatable and that amount will vary over time, but medical studies have traditionally used this concept to define accountability. QALY has recently been prohibited from being used in deciding reimbursement out of fear that it might lead to rationing health care. Yet some measurement of dollar cost must be factored in, even one that is slightly flexible, since avoiding accountability entirely condemns our medical system to failure.

Although examples abound, a recently FDA approved medication illustrates both the difficulty and the importance of determining value in medical care. The new medication, Provenge, was approved this past year for the treatment of late stage prostate cancer. Prostate cancer usually is an incidental finding in elderly men, but, at times, can aggressively spread, primarily to bones, causing pain and even death. Since prostate cancer is sensitive to male hormones, using injections to remove all male hormones from the body usually relieves the pain and improves survival. Unfortunately most prostate cancer will eventually lose its sensitivity to hormone manipulation and once again progress. It is for this type of metastatic prostate cancer, for which no good therapy is currently available, that Provenge was approved.

Provenge treatment involves a clever approach in which cells are removed from the cancer patient, incubated in a laboratory with cancer specific proteins, and then transfused back into the patient. If we ever hope to find a cure for cancers, novel treatments like this need to be tried. For their ingenuity, the investigators and the manufacturers of Provenge deserve praise. Unfortunately, in the case of Provenge, the treatment does not work very well, adding an average of just four months of life at a cost of about $93,000. This translates in $280,000 for one QALY, far in excess of the usually accepted cost-effective levels. In spite of the high price tag and marginal benefit, Medicare, which is legally restricted from considering price, has agreed to pay for this treatment. The total cost for Medicare of Provenge is predicted to exceed one billion dollars yearly, worsening the problems of our financially strained system.

This example illustrates the question that needs to be addressed. Do we require that a treatment, even if minimally beneficial and very expensive, must be paid for by government or private insurance? Do we allow lobbies, either business or patient advocate lobbies, to pressure legislators into mandating insurance coverage for policies that are not cost-effective? For an elected official to take the position, that value is required in health care just like every other thing we purchase, is emotionally charged and politically difficult. Without the resolve and courage necessary to make those decisions, unfortunately, there never will be a solution for our health care problems.