Drs. Peter Ubel, Amy Abernethy and Yousuf Zafar, all medical doctors, published an editorial in
The
New England Journal of Medicine
entitled “Full Disclosure—Out-of-Pocket Costs as Side Effects.”
An abbreviated version by Dr. Ubel appeared as an op-ed in The
New York Times as “Doctor,
First Tell Me What It Costs.” They argue
that, just as doctors typically discuss negative side effects of
drugs and medical treatments with their patients, they should also
discuss the financial cost of drugs and medical treatments before the
patient makes a decision. These costs should be treated as a
potential side-effects because stress from the threat of financial ruin can
adversely affect the patient's health. They note that cost
is sometimes not discussed because both patients and doctors are too
embarrassed to bring it up.
Bevacizumab
(or Avastin), a drug which extends the lives of colorectal cancer
sufferers an average of five months beyond chemotherapy alone, has a
median price of $44,000. A patient on Medicare would be responsible
for 20% of that cost, or $8800.
A breast
cancer patient with a high deductible health insurance policy faces
average out-of-pocket costs of $55,000—obviously, more than the
life savings of most Americans. A person with a high deductible
plan faces a bill of $40,000 for myocardial infarction, and $4,000
per year for management of “uncomplicated” diabetes. (Meanwhile
employers are increasingly shifting workers to insurance policies with higher co-payments and deductibles.)
The authors state four reasons it would be beneficial for doctors to inform patients in
advance of the cost of treatment. My comments on each are in
parentheses.
Informing
the patient of the cost of treatment may cause some patients to
switch to a less expensive alternative treatment that is just as
effective. (Why would a doctor ever
recommend a drug or treatment if there is an equally effective and
less expensive alternative?)
Some patients
may be “willling to trade off some chance of medical benefit” in
exchange for lower cost. (This possibility, which the authors refer
to as “complex and ethically charged,” gets to the heart of the
matter. Some patients may choose to forego treatment rather than leave themselves or their families bankrupt. It is implied that knowing the full cost of treatment may persuade some folks to commit passive suicide.)
Patients could
attempt to obtain financial assistance in advance of the treatment.
(An example is given of someone who was able to obtain help from a
charity—a rare event, at best.)
“A growing
body of evidence” suggests that if patients take cost into
account, it “might reduce costs for patients and society in the
long term.” (However, there is no citation to this body of
evidence and the authors do not elaborate. They may mean that
if everyone became more cost-conscious, prices might come down, but
does the health care industry operate the same way as other more competitive markets?)
It
seems so obvious that doctors should discuss costs with patients that
it hardly seems necessary for NEJM
to publish an editorial suggesting that they do so. But the most
revealing thing about this article is the issues Ubel and his
colleagues don't even mention.
First of all, they don't ask why the
costs of drugs and medical treatment are so much higher in this
country than in other industrialized countries.
Medical costs are treated as if they were merely an uncontroversial
feature of the natural environment, and no mention is made of how they might be reduced.
There is some objective data comparing the causes of our higher
prices. A 2012 study by the Institute of Medicine, a division of the National Academy of Sciences, estimated that the U. S. health care system wastes $750 billion a year, roughly 30% of the money spent. The report identified six major areas of waste: unnecessary services ($210 billion annually), inefficient delivery of care ($130 billion), excess administrative costs ($190 billion), inflated prices ($105 billion), prevention failures ($55 billion), and fraud ($75 billion).
Our doctors are more highly compensated than doctors in the rest of the world.
Our hospitals attempt to maximize their profits,
regardless of whether they are legally registered as for-profit or
nonprofit corporations. Part of the problem is political corruption.
For example, when Congress expanded Medicare to include prescription
drug coverage,
Medicare was forbidden to use its purchasing power to negotiate for lower drug prices.
More
importantly, the authors don't even question why it is
necessary for so many Americans to choose between financial
ruin and illness or death when they suffer from common medical conditions.
They fail to mention that the rest of the world's developed countries have largely solved this dilemma by establishing government run
single payer health care systems. If this were merely a matter of
money, we could talk about the vast sums this country wastes on
overseas military misadventures, or the way our billionaires grow increasingly rich while paying lower tax rates than their
secretaries. But these outrages are irrelevant, since a single payer system will save money. All the countries with single payer spend less per capita on health care than we do.
To be fair,
Ubel does say, “No one should have to suffer unnecessarily from the cost
of medical care.” But he fails to pursue any of the implications of this
remark. The authors never make the point that single payer
would almost certainly solve many of the financial problems they agonize over in these articles. I suppose it's possible Ubel and his colleagues are secretly hoping to build momentum for single payer by encouraging doctors to empathize more with their patients, but there's nothing in the article to support this speculation.
To paraphrase a point frequently made by Noam Chomsky, no one becomes a tenured professor at an elite university, or is invited
to write an editorial for
The New York Times, unless
he or she has completely internalized the world view of the ruling class, and in the process learned to ignore all the really important
issues facing our society.
