Rationing health care


Obama's Medicare czar faces life-and-death decisions
Washington Examiner Editorial, 2010-08-16

Two organizations not known as members of the Vast Right Wing Conspiracy
are worried that
President Obama’s recess-appointed Medicare czar
won’t allow the government health care program
to cover two FDA-approved anti-cancer drugs
with proven records of extending patients’ lives.

The FDA approved Provenge, which is used to fight prostate cancer,
and Avastin, which is used to delay the spread of breast cancer
after it appears elsewhere in the body.
The problem is that Dr. Donald Berwick,
the man Obama recess-appointed
as administrator of the Centers for Medicare and Medicaid,
appears to be considering denying Medicare reimbursement
for patients using Provenge and Avastin.

The Ovarian Cancer National Alliance explains the problem:
“Medicare must cover therapies that are ‘reasonable and necessary,’
while the FDA is instructed to approve drugs that are ‘safe and effective.’
Because of the conflicting federal coverage and approval requirements,
there are some non-FDA approved drugs (called off-label drugs)
that are paid for by CMS.
However, with respect to Provenge,
it appears that CMS is arguing that
while the treatment is safe and effective,
it may not be reasonable and necessary.
For the first time,
an FDA approved anti-cancer therapy may not be covered by Medicare.”

The same problem has developed on Avastin,
according to the Susan G. Komen Fund,
which has joined with OCNA advocating for Medicare coverage of both drugs.
With respect to Avastin,
Komen’s founder and, CEO, Ambassador Nancy Brinker, said
“We recognize the benefits of Avastin overall
are modest for women with metastatic breast cancer.
However, we do know that for some women,
Avastin offers a greater than modest benefit.
We hope that this decision will not restrict access to Avastin to all patients.”
Brinker added that
“the decision to use Avastin should be made between a woman and her doctor
after a thoughtful conversation
that carefully considers the drug’s benefits and risks.
Komen does not want to see access limited by Medicare and Medicaid.”

Berwick has been on the job barely a month,
but already faces momentous life-and-death medical coverage decisions
that Obamacare critics said were inevitable
and would smack of death panel-like deliberations.
This is the same Berwick who said in 2009 that
“the decision is not whether or not we will ration health care.
The decision is whether we will do it with our eyes open.”

There are cost considerations with both Provenge and Avastin,
with the former estimated to cost $23,000 per added month of life,
and the latter being effective
with some women suffering from an advanced stage of breast cancer,
but not with others.
Will Berwick give a few extra months of living to cancer sufferers
or let them die sooner in order to save a few bucks for the government?

[My opinion:
Nobody is worth spending $23,000 per month on just to keep them alive.
The country can't afford it.
It's not worth it.
No matter who you are.

After thinking things over overnight,
I would take a slightly less absolute view
and make several exceptions:
  1. Those whose health was damaged by their occupation
    should certainly be made as whole as possible
    (with a limit mentioned below).
    An obvious example would be
    those injured in the line of government service,
    especially from fighting America’s wars.
    The limit would, painfully, be a statute of limitations
    on how long care above the normal limits would last.
    Suppose, hypothetically, a wounded veteran could be made whole,
    but at a cost, say, of $1 million per year.
    It would, to me, make sense to say, regretfully,
    that after a normal lifespan, whatever that is,
    the country could no longer afford to keep him alive
    (say beyond the age of 85).
    Obviously there is room to fine tune this issue.

  2. I have a soft spot in my heart for parents.
    I feel they perform a function to society, that of parenting.
    Therefore, I think parents of children under the age of 18,
    if requiring medical attention,
    would deserve unusually generous health care,
    until all of their children reach 18.

  3. Restrictions on spending, as I see them,
    would only apply to spending by government plans (Medicare, etc.)
    and private health insurance,
    i.e., where the spending is spread over, essentially, all of society.
    If individuals want to spend their own money,
    above and beyond the public or insurance largesse,
    on their health care,
    I certainly can see no reason in a free society
    why they should not have the right
    to spend their money on anything they wish,
    certainly including their own health care.
    If Bill Gates should require or desire some super-expensive medical treatment,
    why not allow him to pay for it?

Review of prostate cancer drug Provenge
renews medical cost-benefit debate

By Rob Stein
Washington Post, 2010-11-08