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tantalus
02 Dec 15,, 19:09
Assuming (a big one) we are not presenting the free market an opportunity to write all the blank price tags the article discusses.

And discussing the matter in the backdrop of a drastically ageing population in many countries, with societies populated with ever more demanding and risk averse citizens, this really is a big issue.


Human life is so precious, it seems crass to put a price on it. How can a pile of coins, paper or gold bars match a year on Earth? Life should be, quite literally, invaluable.

Yet that is the morbid question that health services, everywhere, inevitably have to ask. They have limited money to spend on sick and dying people, and whenever a new drug becomes available, they have to make a choice: will the few stolen months, or years, be worth the money it costs?

Our gut instincts may seem obvious: we should do all that we can to buy more time for the people we love. Yet Dominic Wilkinson, an intensive care doctor and ethicist at the University of Oxford’s Uehiro Centre for Practical Ethics recently wrote a thought-provoking article questioning these assumptions and asks us all to consider just how much we should be willing to pay for a longer life.

Intrigued, BBC Future phoned him to explore his argument, and to better understand the ways we currently calculate the price of life.

At the moment, drugs for terminal illnesses tend to be judged on two things – by how much they extend the lifespan, and the quality of life of the patient, using a scale known as the Quality Adjusted Life Year-saved (QALY). A drug that helps you live for an extra year, at half your general quality of life, would score about 0.5 years on this scale, for instance. “Alternatively, a drug that improved your quality of life for a year from a level of half normal, to full health would also score 0.5,” explains Wilkinson.

From these calculations, a health service can then start to set a price on whether a drug is worth the cost. The UK’s recommendations, for example, are about £20,000 to £30,000 ($30,000 to $45,000) for each additional year of good health, once it has been adjusted to take into account the quality of life. So a drug that achieved 0.5 on the QALY measure would only merit £10,000-15,000 ($15,000 to $22,500).

This inevitably means that some drugs have been rejected by the National Health Service (NHS), because they are simply too expensive: the breast cancer drug Kadycla, for instance, only extends the lifespan by about six months for a cost of £95,000. Even if the quality of life during those few months is equal to that of a healthy person, it still hugely overstretches the limit. (Other healthcare providers may have different criteria, of course – but they all have to weigh up the costs and benefits in some way, before offering to fund a treatment.)

Campaigners argue that the pharmaceutical companies should lower the costs of such treatments, and that health services should also invest more and more money in drugs that will buy terminally ill patients some more precious time. Given these strong and emotive arguments, the UK recently considered increasing the threshold for terminal illnesses – to as much as £80,000 ($120,000) for each “quality-adjusted year saved”.

Wilkinson says this attitude is completely understandable – and it’s often the doctors, as well as the patients themselves, who argue the case. “As doctors looking after patients, we are ethically driven to advocate for patients, to say that ‘I know it is expensive but my first duty is to help my patient,’” he says.

But the inevitable sacrifice is that this money will be taken away from other areas of care, such as mental health services or help for people with disabilities – measures that may be crucial for improving the quality of life for people at the start or middle of their lives.

Is it worth forfeiting one person’s comfort to buy another a few more months at the end of their life? When making these decisions, it’s important to gauge public opinion. And although you might assume that most people would pay infinite sums to buy a few extra years, recent research suggests we do not all place such a high value on the sheer length of the lifespan.

Wilkinson points to a detailed UK study of 4,000 people that clearly explained the different ways the health service’s limited resources could be spent, and asked the participants for their preferences. “They clearly indicated that they weren’t comfortable with giving more money to people who were terminally ill, compared with people who might benefit at other stages of their lives.”

Perhaps most surprising were the results from a study in Singapore, which questioned elderly, but otherwise healthy, citizens as well as those suffering from terminal cancer. “The striking thing from that is that they were prepared to pay an awful lot more money for palliative care so they could be treated in their own home, than drugs that would extend life,” says Wilkinson.

On average, the participants would pay £5,000 ($7,500) for a treatment to extend life by a year. But they were willing to pay about twice that amount – £10,000 ($15,000) – on better palliative care, such as better nursing that would allow them to die in the relative comfort of their homes, rather than a hospital. “It seemed to provide a fresh way of thinking about difficult decisions.”

Clearly, these studies are not the final answer; it is hard to know if these opinions are shared among different people in different cultures and facing different illnesses; there are also questions about just how effectively a calculation like the QALY scale can really, objectively assess a treatment’s potential. But Wilkinson thinks that we should at least consider these different opinions before devoting more and more money to extending lifespans.

“Although it’s very understandable to want to buy more expensive drugs for the terminally ill, I don’t think it reflects the view of the general public or those of the patients,” he says. “Nor is it clearly the right ethical approach.”

As the population ages, and healthcare grows ever more advanced, and expensive, these issues will only become more pressing. The eminent American surgeon Atul Guwande has long questioned whether it is better to stretch out the lifespan, instead of increasing the comfort of our available years.

Ezekiel Emanuel, the former director of the Clinical Bioethics Department at the US National Institutes of Health, has even claimed that he would refuse all life-extending healthcare at the age of 75, rather than entering a cycle of ever more intense treatments to draw out his last few years.

Few of us may decide to take such a drastic decision, but anyone, at any age, may do well to consider the value of their time on Earth and what we are doing to make the most of it.

http://www.bbc.com/future/story/20151201-how-much-would-you-pay-to-live-for-an-extra-year

DOR
03 Dec 15,, 11:58
I think it's called "triage," but maybe someone with more knowledge can correct me. In a situation where there is limited ability to provide maximum attention to every case, those providing that attention have to decide where their skill can best be utilized, where it can be provided with a delay, and where provision is unlikely to be useful, given the other demands.

All healthcare is rationed, regardless of the system, because of the special nature of its demand (think of demand for air under water).

It may be rationed by price, as in the US.
It may be rationed by time, as in many states with national healthcare benefits.
It may be rationed by quality, as in much of the Third World.

In reality, combinations are most common.

Can anyone think of an example of high quality care being readily available at extremely low cost?

gunnut
03 Dec 15,, 18:46
i think it's called "triage," but maybe someone with more knowledge can correct me. In a situation where there is limited ability to provide maximum attention to every case, those providing that attention have to decide where their skill can best be utilized, where it can be provided with a delay, and where provision is unlikely to be useful, given the other demands.

All healthcare is rationed, regardless of the system, because of the special nature of its demand (think of demand for air under water).

It may be rationed by price, as in the us.
It may be rationed by time, as in many states with national healthcare benefits.
It may be rationed by quality, as in much of the third world.

In reality, combinations are most common.

Can anyone think of an example of high quality care being readily available at extremely low cost?

like!

The job can be done fast, cheap, or well. We can only get two out of the three.

We can either have it done fast and cheap, but not well.
We can have it done cheap and well, but it won't be fast.
Or we can have it done fast and well, and it will be expensive.

That's the nature of a world with limited resources.

tantalus
03 Dec 15,, 20:23
Can anyone think of an example of high quality care being readily available at extremely low cost?
Well yes, if I can cheat, much of modern healthcare is high quality if not magic compared to centuries past, and is affordable to billions.

For states that provide extensive state funded healthcare it would be best to ask the tough questions and perhaps follow through with some unorthodox solutions.

The idea of focusing on care over treatment, quality over quantity, is not something central in minds society at the moment, it should be evaluated. While it will always be a combination, we are leaning heavily in one direction. Incidentally the free market is likely to continue to push in that direction. This will be the century of biology and biotechnology, personalised healthcare for the individual at a genetic level, possibly greatly extended lifespans, as always, there is an opportunity to get out in front of the issue, a value and economic based discussion that could inform policy makers proactively.

DOR
04 Dec 15,, 11:27
like!

The job can be done fast, cheap, or well. We can only get two out of the three.

We can either have it done fast and cheap, but not well.
We can have it done cheap and well, but it won't be fast.
Or we can have it done fast and well, and it will be expensive.

That's the nature of a world with limited resources.

Welcome to the world of health care financing reform.
The lessons painfully learned were very good ones, but I'm glad to be out of that particular ring of hell, at least for now.

GVChamp
04 Dec 15,, 23:20
Triage isn't exactly the same. Triage specifically refers to emergency environments when health care resources are overwhelmed. Health care professionals need to eye-ball patients and ascertain a level of required care quickly.

Only one doctor and 10,000 patients after a plane crash....some people are going to die.

This is a more dispassionate policy analysis. It's used in a lot of different fields because you need some sort of standard for whether a medicine or regulation is "worth" it.
So....new cancer drug costs $100,000 but prolongs life 3 months...worth it?

You need some sort of standard or else you end up paying for everything. You can't pay for everything.

This is also used to evaluate regulations. EPA apparently uses a value of $9.1 million. That means if treating chemicals costs $200 million but only saves 5 lives, those chemicals are probably going to be dumped into the water un-treated and 5 people will die because of it.

https://en.wikipedia.org/wiki/Value_of_life#Life_Value_in_the_US

But you need some sort of standard.

tbm3fan
05 Dec 15,, 08:45
Wilkinson says this attitude is completely understandable – and it’s often the doctors, as well as the patients themselves, who argue the case. “As doctors looking after patients, we are ethically driven to advocate for patients, to say that ‘I know it is expensive but my first duty is to help my patient,’” he says.

What doctors say concerning their patients and below an article on what doctors want done we they are in the same boat.

http://www.zocalopublicsquare.org/2011/11/30/how-doctors-die/ideas/nexus/


How Doctors Die
It’s Not Like the Rest of Us, But It Should Be
docs_die_grave_pic

by Ken Murray | November 30, 2011

Years ago, Charlie, a highly respected orthopedist and a mentor of mine, found a lump in his stomach. He had a surgeon explore the area, and the diagnosis was pancreatic cancer. This surgeon was one of the best in the country. He had even invented a new procedure for this exact cancer that could triple a patient’s five-year-survival odds–from 5 percent to 15 percent–albeit with a poor quality of life. Charlie was uninterested. He went home the next day, closed his practice, and never set foot in a hospital again. He focused on spending time with family and feeling as good as possible. Several months later, he died at home. He got no chemotherapy, radiation, or surgical treatment. Medicare didn’t spend much on him.

It’s not a frequent topic of discussion, but doctors die, too. And they don’t die like the rest of us. What’s unusual about them is not how much treatment they get compared to most Americans, but how little. For all the time they spend fending off the deaths of others, they tend to be fairly serene when faced with death themselves. They know exactly what is going to happen, they know the choices, and they generally have access to any sort of medical care they could want. But they go gently.

Of course, doctors don’t want to die; they want to live. But they know enough about modern medicine to know its limits. And they know enough about death to know what all people fear most: dying in pain, and dying alone. They’ve talked about this with their families. They want to be sure, when the time comes, that no heroic measures will happen–that they will never experience, during their last moments on earth, someone breaking their ribs in an attempt to resuscitate them with CPR (that’s what happens if CPR is done right).

Almost all medical professionals have seen what we call “futile care” being performed on people. That’s when doctors bring the cutting edge of technology to bear on a grievously ill person near the end of life. The patient will get cut open, perforated with tubes, hooked up to machines, and assaulted with drugs. All of this occurs in the Intensive Care Unit at a cost of tens of thousands of dollars a day. What it buys is misery we would not inflict on a terrorist. I cannot count the number of times fellow physicians have told me, in words that vary only slightly, “Promise me if you find me like this that you’ll kill me.” They mean it. Some medical personnel wear medallions stamped “NO CODE” to tell physicians not to perform CPR on them. I have even seen it as a tattoo.

To administer medical care that makes people suffer is anguishing. Physicians are trained to gather information without revealing any of their own feelings, but in private, among fellow doctors, they’ll vent. “How can anyone do that to their family members?” they’ll ask. I suspect it’s one reason physicians have higher rates of alcohol abuse and depression than professionals in most other fields. I know it’s one reason I stopped participating in hospital care for the last 10 years of my practice.

How has it come to this–that doctors administer so much care that they wouldn’t want for themselves? The simple, or not-so-simple, answer is this: patients, doctors, and the system.

To see how patients play a role, imagine a scenario in which someone has lost consciousness and been admitted to an emergency room. As is so often the case, no one has made a plan for this situation, and shocked and scared family members find themselves caught up in a maze of choices. They’re overwhelmed. When doctors ask if they want “everything” done, they answer yes. Then the nightmare begins. Sometimes, a family really means “do everything,” but often they just mean “do everything that’s reasonable.” The problem is that they may not know what’s reasonable, nor, in their confusion and sorrow, will they ask about it or hear what a physician may be telling them. For their part, doctors told to do “everything” will do it, whether it is reasonable or not.

The above scenario is a common one. Feeding into the problem are unrealistic expectations of what doctors can accomplish. Many people think of CPR as a reliable lifesaver when, in fact, the results are usually poor. I’ve had hundreds of people brought to me in the emergency room after getting CPR. Exactly one, a healthy man who’d had no heart troubles (for those who want specifics, he had a “tension pneumothorax”), walked out of the hospital. If a patient suffers from severe illness, old age, or a terminal disease, the odds of a good outcome from CPR are infinitesimal, while the odds of suffering are overwhelming. Poor knowledge and misguided expectations lead to a lot of bad decisions.

But of course it’s not just patients making these things happen. Doctors play an enabling role, too. The trouble is that even doctors who hate to administer futile care must find a way to address the wishes of patients and families. Imagine, once again, the emergency room with those grieving, possibly hysterical, family members. They do not know the doctor. Establishing trust and confidence under such circumstances is a very delicate thing. People are prepared to think the doctor is acting out of base motives, trying to save time, or money, or effort, especially if the doctor is advising against further treatment.

Some doctors are stronger communicators than others, and some doctors are more adamant, but the pressures they all face are similar. When I faced circumstances involving end-of-life choices, I adopted the approach of laying out only the options that I thought were reasonable (as I would in any situation) as early in the process as possible. When patients or families brought up unreasonable choices, I would discuss the issue in layman’s terms that portrayed the downsides clearly. If patients or families still insisted on treatments I considered pointless or harmful, I would offer to transfer their care to another doctor or hospital.

Should I have been more forceful at times? I know that some of those transfers still haunt me. One of the patients of whom I was most fond was an attorney from a famous political family. She had severe diabetes and terrible circulation, and, at one point, she developed a painful sore on her foot. Knowing the hazards of hospitals, I did everything I could to keep her from resorting to surgery. Still, she sought out outside experts with whom I had no relationship. Not knowing as much about her as I did, they decided to perform bypass surgery on her chronically clogged blood vessels in both legs. This didn’t restore her circulation, and the surgical wounds wouldn’t heal. Her feet became gangrenous, and she endured bilateral leg amputations. Two weeks later, in the famous medical center in which all this had occurred, she died.

It’s easy to find fault with both doctors and patients in such stories, but in many ways all the parties are simply victims of a larger system that encourages excessive treatment. In some unfortunate cases, doctors use the fee-for-service model to do everything they can, no matter how pointless, to make money. More commonly, though, doctors are fearful of litigation and do whatever they’re asked, with little feedback, to avoid getting in trouble.

Even when the right preparations have been made, the system can still swallow people up. One of my patients was a man named Jack, a 78-year-old who had been ill for years and undergone about 15 major surgical procedures. He explained to me that he never, under any circumstances, wanted to be placed on life support machines again. One Saturday, however, Jack suffered a massive stroke and got admitted to the emergency room unconscious, without his wife. Doctors did everything possible to resuscitate him and put him on life support in the ICU. This was Jack’s worst nightmare. When I arrived at the hospital and took over Jack’s care, I spoke to his wife and to hospital staff, bringing in my office notes with his care preferences. Then I turned off the life support machines and sat with him. He died two hours later.

Even with all his wishes documented, Jack hadn’t died as he’d hoped. The system had intervened. One of the nurses, I later found out, even reported my unplugging of Jack to the authorities as a possible homicide. Nothing came of it, of course; Jack’s wishes had been spelled out explicitly, and he’d left the paperwork to prove it. But the prospect of a police investigation is terrifying for any physician. I could far more easily have left Jack on life support against his stated wishes, prolonging his life, and his suffering, a few more weeks. I would even have made a little more money, and Medicare would have ended up with an additional $500,000 bill. It’s no wonder many doctors err on the side of overtreatment.

But doctors still don’t over-treat themselves. They see the consequences of this constantly. Almost anyone can find a way to die in peace at home, and pain can be managed better than ever. Hospice care, which focuses on providing terminally ill patients with comfort and dignity rather than on futile cures, provides most people with much better final days. Amazingly, studies have found that people placed in hospice care often live longer than people with the same disease who are seeking active cures. I was struck to hear on the radio recently that the famous reporter Tom Wicker had “died peacefully at home, surrounded by his family.” Such stories are, thankfully, increasingly common.

Several years ago, my older cousin Torch (born at home by the light of a flashlight–or torch) had a seizure that turned out to be the result of lung cancer that had gone to his brain. I arranged for him to see various specialists, and we learned that with aggressive treatment of his condition, including three to five hospital visits a week for chemotherapy, he would live perhaps four months. Ultimately, Torch decided against any treatment and simply took pills for brain swelling. He moved in with me.

We spent the next eight months doing a bunch of things that he enjoyed, having fun together like we hadn’t had in decades. We went to Disneyland, his first time. We’d hang out at home. Torch was a sports nut, and he was very happy to watch sports and eat my cooking. He even gained a bit of weight, eating his favorite foods rather than hospital foods. He had no serious pain, and he remained high-spirited. One day, he didn’t wake up. He spent the next three days in a coma-like sleep and then died. The cost of his medical care for those eight months, for the one drug he was taking, was about $20.

Torch was no doctor, but he knew he wanted a life of quality, not just quantity. Don’t most of us? If there is a state of the art of end-of-life care, it is this: death with dignity. As for me, my physician has my choices. They were easy to make, as they are for most physicians. There will be no heroics, and I will go gentle into that good night. Like my mentor Charlie. Like my cousin Torch. Like my fellow doctors.

Ken Murray, MD, is Clinical Assistant Professor of Family Medicine at USC.

gunnut
08 Dec 15,, 01:52
So....new cancer drug costs $100,000 but prolongs life 3 months...worth it?

Evil, greedy drug companies should not be allowed to gouge patients like that. If elected, I will propose legislations restricting life saving drugs to be no more than $3 a day.

tbm3fan
08 Dec 15,, 07:22
Evil, greedy drug companies should not be allowed to gouge patients like that. If elected, I will propose legislations restricting life saving drugs to be no more than $3 a day.

Actually they pretty much are in many cases. Yet since you don't prescribe drugs, much less need to use diagnostics, then you have no idea what has happened in the last 12 months in regards to prices that were downright cheap for some in 2014. Me, I do both, so have better knowledge of what is going on behind the scenes.

tantalus
08 Dec 15,, 16:47
What doctors say concerning their patients and below an article on what doctors want done we they are in the same boat.

http://www.zocalopublicsquare.org/2011/11/30/how-doctors-die/ideas/nexus/


How Doctors Die
It’s Not Like the Rest of Us, But It Should Be

like