Doctors consider cost of treatment in making medical decisions

Doctors are as aware of the seemingly endless rise in health care costs as the rest of us. Much of this increase is attributable to the introduction of new specialty drugs. Several major medical specialty groups are examining this issue using cost-benefit analysis. Doctors are investigating whether the extra benefit to patients of new, expensive drugs justify their use instead of less expensive alternatives that do not provide that extra benefit.

Several medical groups, including oncologists and cardiologists, are developing guidelines to aid physicians in choosing appropriate treatment which guidelines are based, at least in part, on the cost of the treatment. This is a significant departure from doctors basing treatment decisions purely on what the physician believes is the most efficacious treatment without regard to cost.

A recent article in The New York Times examined this issue. We can all agree that while the quality of medical treatment is of paramount importance, reducing or at least significantly slowing the rise in the total amount our country spends on medical treatment is beneficial for our society. Yet, this goal necessarily raises many ethical issues. Take the situation where a person in the last stages of life. Who determines how much benefit a patient will get from an expensive drug, and whether the cost of that drug makes the treatment a good buy? If you have a disease for which there is a very expensive drug that could increase your life expectancy by a few months, or if you can be helped, but not cured of a disease by being prescribed a very expensive drug, who makes the decision on whether the cost of the drug is justified? This is clearly a case of rationing medical care, but is it justified? To the patient who lives a few more months and who has some relief of symptoms for a short period of time there is only one answer: give me the best possible treatment even if it doesn’t help a great deal.

Who pays for the expensive treatment also impacts how doctors address this issue. If a patient has terrific health insurance which pays for the expensive medication is a doctor more likely to prescribe that medication than if the patient is a self-pay and has to spend tens or hundreds of thousands of dollars, assuming, of course, our hypothetical patient has that type of money? Doctors are beginning to take the patient’s ability to pay, and what happens to the patient and his family if all their resources are used to pay for marginal health benefits.

These issues will not go away. As the drug industry develops specialty drugs that are incredibly expensive, can we as a society continue to pay for the treatment, regardless of the likelihood that treatment will have any meaningful impact on the patient? Who will decide that a cheaper drug that is almost, but not quite as good as the more expensive one should be substituted?

These are thorny questions for which there is no easy answer. However, establishing guidelines for the use of specific medication and treatments will hopefully provide both patients and physicians with a roadmap for choosing among the various alternatives, taking into account the amount of good each therapy provides and the cost of such therapy.