There may be a very small number of regular readers of this column that would consider it perfectly OK to spend $200,000 to have exclusive personal use of a high performance car like a Maserati GranTurismo MC Stradale for a single year. Good luck to them; they clearly have the annual income to afford it. For most of us, it ain’t gonna happen, and we know it. It’s more than a lot of us of us may have paid for a home that we started to pay for 15, 20, or 30+ years ago.
However, we appear to have an utterly different set of expectations when it comes to health care (and cancer care specifically) — and so do at least some of our doctors!
Two articles published this week, both based on recent data reported in the journal Health Affairs, looked at what physicians and patients thought were reasonable costs to pay for each additional year of life for a person with late stage cancer.
- 4,800 patients placed valuations on treatments for metastatic cancer that were 24 times the actual cost (on average).
- The actual average annual cost of treatment for colorectal cancer, female breast cancer, cancer of the head and neck, or lung cancer was $7,321; the average value placed on such treatment by patients was $180,284 (a benefit-cost ratio of 24.6).
- The actual average annual cost of treatment for metastatic colorectal cancer was $10,775; the estimated annual willingness to pay given by patients was $251,567 (a benefit-cost ratio of 23.3).
- Standard methods used to estimate the value of these treatments for late stage cancers (e.g., quality-adjusted life years [QALYs]) massively undervalued these treatments from a patient perspective.
Where are these patients expecting to be able to find $250,000 if they suddenly found they needed this to pay for their treatment?
In an article on Medscape, Nick Mulcahy looks at data published by Ubel et al. in the same issue of Health Affairs. This study asked oncologists in the USA (n = 788) and Canada (n = 158) how much benefit a new cancer treatment needed to provide to justify its cost. In this case,
- About half the oncologists thought, in the abstract, that $50,000 to $100,000 was a reasonable cost per life-year saved. However, …
- Faced with a hypothetical case of an individual patient with metastatic cancer, the American and the Canadian oncologists endorsed “much higher cost-effectiveness ratios, often several hundred thousand dollars per life-year gained.”
In the case of this second study, the first reported figure of $50,000 to $100,000 per QALY is one commonly used by health economists as a reasonable estimate of the value of a year of life for a person with metastatic disease. Clearly, however, the oncologists were unable to correlate their abstract estimates of reasonableness from the very personal estimates of reasonableness when faced with an individual patient.
Where do these doctors think that their patients are going to find “several hundred thousand dollars” at the drop of a hat?
The problem, of course, is that very few of the readers of this column — or indeed of all the cancer patients in most of the developed world, or their oncologists — ever have to actually pay the full costs for such therapies. They are (largely) paid for by insurance companies and governments and self-insured companies. Our expectations have been divorced from reality. If we really had to pay for these treatments ourselves at the costs suggested, we would simply understand we couldn’t do it. And I am not just talking about the poor. Families with incomes of $250,000 a year would be hard-pressed to consider the idea of paying $200,000 to keep Grandma alive for an extra year — even if that extra year of life could be guaranteed!
But for some reason we also seem to think that it is reasonable that our insurance companies or our governments or our employers should be able to pay these sums — even though we know we can’t. So let’s try to give this some real context:
- Let’s say that it really did cost $250,000 a year to keep a single person with metastatic, castration-resistant prostate cancer (mCRPC) alive with good quality of life for a single year.
- There are some 30,000 men who are going to die of prostate cancer in America each year, and almost all of those men are going to die with mCRPC.
- So … the cost of keeping these 30,000 men alive for a single additional year would be 30,000 x $250,000 = $7.5 billion.
$7.5 billion is a number that insurance companies and governments (let alone self-insured companies) look at and, just like you and I as individuals, say “We just can’t afford to pay that!” And that’s just for the 30,000 men who will die with mCRPC. It ignores the healthcare needs of the other 311.97 million Americans. It also ignores the costs of the doctors and the nurses needed to treat these 30,000 men with mCRPC and a whole other bunch of things too — like hospice care for the last 3 months of their lives.
I want to be able to extend the life (and the quality of life) of men with mCRPC just as much and probably more than the average man in the street … but if we don’t get a grip on the economic realities of what it really costs to develop and deliver effective medicines to the people who need them, we will soon have no new medicines at all that most of us can afford.
It may even become challenging for those who can currently afford the Maserati, because as demand for for rare products declines, their cost goes up. Will they be able to afford $2 million for an additional year of life? Maybe they’ll just have to settle for the Maserati for 6 months.
In my case, I already know I can’t afford the Maserati … but, in the spirit of full disclosure, I was able to scrape up the money for a “previously owned” (that means “second hand”) Jaguar a few years ago at the bottom of the market. I drive this sparingly. Most of the time I use a Subaru with > 100,000 miles on the clock!