A Patient Complained about the Cost of Her Medical Care. Here's How Her Doctor Responded.

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The oncologist had prescribed Xgeva hoping it would strengthen her bones while also delaying the progression of Angela Kahn’s breast cancer. But Kahn (a pseudonym) couldn’t get over the price of the drug. Before the oncologist had a chance to ask how she was feeling, she blurted out that the medication cost “$15,000 a shot.” “That’s crazy,” the oncologist replied, continuing by saying the price “fits right in with the rest of the insanity” of U.S. healthcare pricing. At that price, Kahn concluded, “I don’t think I should get it.”

The oncologist assured her “You’re getting it,” and they both laughed.
Not that either thought Xgeva’s price was a laughing matter. In fact, like many medications, Xgeva costs much more in the U.S. than in any other developed countries, with a single injection costing more than $2,000.
There’s too many reasons for these high prices to delve into them in the space of a short essay. Instead, I want to show how the insanity of American healthcare prices played out in this one, real oncology appointment. (Note: The appointment was recorded by a marketing company, Verilogue Inc., with the permission of the doctor and patient. I gained access to an anonymized transcript of the appointment for a research project approved by the Duke University IRB.)
After assuring Kahn that she’d remain on the Xgeva, her oncologist explained how he believes healthcare pricing plays out in the U.S. “It’s totally outrageous. What usually happens is the hospital or the clinic will charge 300 times what they think they can get, and the insurance company pays 1/20th of the original.”
“Oh, okay,” Kahn replied, with a touch of confusion.
“So it’s just a game, it’s a total horrible game,” the oncologist continued. “That’s crazy,” Kahn reiterated.
(To read the rest of this article, please visit Forbes.)

A Drug to Treat Cancer and Heart Disease (Miracle Cure or Media Hype?)

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In a recent New York Times article, physician-author Siddhartha Mukherjee wrote about a clinical trial that he characterized as “beautiful,” for potentially illuminating a surprising connection between heart disease and cancer. Mukherjee is a justifiably acclaimed writer, who publishes regularly in The New Yorkerand The New York Times, and who won a Pulitzer for his bestselling book The Emperor of All Maladies. But I wonder whether the demands of popular writing have caused him to hype a treatment that, while promising, is far from proven.

The treatment targets inflammation by inhibiting an interleukin molecule. Researchers conducted a huge clinical trial to see whether the treatment would reduce the kind of inflammation that damages arteries. But Mukherjee didn’t write about the drug because of its ability to prevent heart attacks or strokes. Instead, he was excited about the trial because a secondary analysis of the data showed a “drop in all cancer mortality” and a “stark decrease” in deaths from lung cancer.
Mukherjee knows that secondary analyses like this need to be viewed with caution. Measure enough outcomes in a clinical trial, and the statistics of chance predict that the intervention will falsely appear to reduce some kind of medical problem or other. He even acknowledges that this cancer finding needs to be replicated. However, he isn’t content to urge readers to remain in a state of scientific caution, proclaiming that “if the benefit holds up in future trials, interleukin-1-beta inhibition could eventually rank among the most effective prevention strategies in the recent history of cancer.”
Holy moly, that’s a misleading sentence!
(To read the rest of this article, please visit Forbes.)

Make Sure Your Doctor Is Treating You and Not Your Blood Tests

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He came to the ER with chest pain, shortness of breath, and atrial fibrillation with a heart rate of almost 120 beats per minute. It wasn’t a heart attack, and it wasn’t some rare disease. He was emergently ill because his physician overreacted to blood tests, and prescribed a thyroid pill he didn’t need.

If your doctor tells you that your thyroid is underactive—that you have “subclinical hypothyroidism”—do what you can to make sure you don’t receive thyroid medicine that could do more harm than good.

According to an article in JAMA Internal Medicine, the 72-year-old patient described above had gone to his doctor several months earlier, with mild, nonspecific physical complaints. The doctor ordered a blood test, which showed a slight elevation in his TSH, or “thyroid stimulating hormone.” TSH is the molecule your body releases when your thyroid isn’t producing enough hormone. When TSH is elevated, it can be a sign that your thyroid gland is underperforming.
In this patient’s case, even though his TSH level was high, the level of thyroid hormone was normal in his blood. That means his situation isn’t straightforward. Suppose his TSH had been elevated at the same time as his thyroid hormone was low. And suppose that he was also showing specific signs of thyroid problems—maybe he was cold all the time, or had a slowing of his heart rate. This constitution of signs and symptoms would be strongly suggestive of hypothyroidism—that extra TSH in his bloodstream might not be up to the task of prodding his thyroid to do its job. In that case, it would be reasonable for his primary care physician to prescribe thyroid hormone replacement, and see if he got better.
(To read the rest of this article, please visit Forbes.)

Is Federal Policy Really to Blame for the High Cost of Cancer Care?

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U.S. healthcare costs have been high for decades, outpacing other developed countries since at least the 1980s. But costs continue to rise, and that is causing many experts to ask why. Some people blame federal policies. As an example, they point to reimbursement policies that create incentives for healthcare providers to consolidate. When hospitals merge with each other, or when hospitals buy out physician practices, healthcare providers gain negotiating leverage over insurers, which enables them to negotiate higher prices.

But what evidence do we have that federal policies are to blame for such consolidation?
(To read the rest of this article, please visit Forbes.)

Why Living in a Rich Country Can Give You Cancer

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As a primary care physician, I have counseled thousands of patients to get cancer screening—blood tests to look for prostate cancer, mammograms to detect impalpable breast cancers, and colonoscopies to find precancerous colon lesions. I’ve even tried to find cancers on physical exam, palpating people’s necks for thyroid growths, for example. The goal of all these screening tests was clear to me—find cancers early and we can get rid of them before they become life-threatening.
All the while, I knew there was a downside to much of my efforts. I was potentially finding “lesions” that, if untouched, would have never harmed my patients. I wasn’t just diagnosing cancer and its predecessors; I was overdiagnosing it. Two studies from Dartmouth physician Gil Welch brings new evidence of the surprising frequency of such overdiagnoses, including surprising data on the epidemic of overdiagnoses in rich countries like the U.S.A.
(To read the rest of this article, please visit Forbes.)

The Benefits of High Health Care Expenditures

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I write frequently about the high costs of healthcare, in the U.S. and in many other parts of the world. And in general, I believe strongly that most developed countries need to look seriously at how they’re spending healthcare dollars, and make great efforts to promote high value medical care. But in trying to control healthcare costs, we must not forget about the benefits of healthcare spending. Consider this picture, from a study by Warren Stevens and colleagues, showing that countries that spent the most on cancer care have also experienced the greatest decline in cancer mortality:

Our efforts to curb healthcare spending need to account for the value of the care we spend our money on.

The Cost of New Cancer Drugs (In One Picture)

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“Specialty drugs” – that’s what they’re called. Not the pills of old, these pharmaceuticals are often given intravenously or through injection. Often more biologic in their synthesis than chemical, they are expensive to produce and often target narrow disease processes, meaning the number of patients likely to benefit from them is much much smaller than, say, the market for blood pressure pills.
High production costs and narrow consumer market – a recipe for high prices! Consider the cost of the many specialty drugs which have entered the oncology market in recent years, here shown in a picture put together by Brad Hirsch and colleagues in Health Affairs:

Health Affairs
Health Affairs

Pretty amazing to look at a picture like this and find yourself asking: Why does Perjeta only cost $70,000 per year?

Unsustainable

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Unsustainable
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This picture shows changes in the cost of treating colon cancer, from 1993-2005. It shows unsustainable growth in these expenditures:
By unsustainable, however, I do not mean unjustifiable. Patients with colon cancer have much better prognoses in 2005 than 1993, in large part due to advances in chemotherapy. Instead what I mean by unsustainable is that the rate of growth in spending can’t continue.
If we continue to grow at this rate, we will overwhelm our ability to pay for such care, even if the care continues to improve. We must keep the unsustainability of the spending trend in mind when we set expectations of pharmaceutical executives – and what we look for in the growth of their annual earnings.
We should keep this unsustainability in mind, also, when remembering that healthcare spending threatens the financial stability of governments, corporations, and individual citizens. We should celebrate improvement in treatment for diseases like colon cancer. But we should remember that at some point in time, spending more on such patients, even if it improves their health, might be beyond our means.

Don't Let Your Physician Tell You What To Do Without Finding Out Your Goals

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A recent study of men with early-stage prostate cancer found no difference in 10-year death rates, regardless of whether their doctors actively monitored the cancers for signs of growth or eradicated the men’s cancers with surgery or radiation.
What does this study mean for patients? Based on research we have conducted on prostate cancer decision-making, the implications are clear: Patients need to find physicians who will interact with them the way a good financial counselor would, taking the time to understand them well enough to help them find the treatment that fits their goals.
Imagine a couple in their 40s who ask a financial counselor for advice on retirement planning, and the counselor tells them how much to invest in domestic and foreign stocks versus bonds versus real estate without asking them about their goals. A good counselor would find out what ages the couple wishes to retire at, what kind of retirement income they hope to live off of, how much risk they are willing to take to achieve their goals, and how devastated they would be if their high return investments go south, forcing them to delay retirement or reduce their retirement spending.
Far too often in medical care, physicians don’t behave like good financial counselors–they give treatment recommendations without taking the time to understand their patients’ goals. Consider early-stage prostate cancer, a typically slow-growing tumor that is not fatal for the vast majority of patients who receive the diagnosis. In some men, the tumor lies indolent for decades.
For that reason, men sometimes choose to monitor their cancers–have their doctors conduct regular blood tests or biopsies to see if the tumor is beginning to spread. Such monitoring has the advantage of being relatively noninvasive, but it can create anxiety for patients who wonder, every six months, whether their next checkup will bring bad news.
For that reason, some men prefer active treatments like surgery or radiation that eradicate their cancers and therefore reduce cancer-related anxiety. But these more active treatments have their own downsides–each treatment is relatively arduous, and they can cause both erectile dysfunction and urinary incontinence.
The choice between active treatment and active monitoring depends on a patient’s goals–on how they view the trade-off between outcomes like cancer-related anxiety and erectile dysfunction. When counseling patients with early-stage prostate cancer, physicians need to help patients focus on these trade-offs.
(To read the rest of this article, please visit Forbes.)
 

PeterUbel