The Fine Line Between Waste and Marginal Benefits

The long-running, all-time favorite cure for our ailing health care system is to rid it of those malign twins, waste and inefficiency. No one has figured out how to do that, but it sounds so commonsensical that they retain their popularity in the face of a massive failure, well over 50 years now, to even make even a little progress against them.

At the same time, we have heard much of late about their first cousin, marginal benefits, which many see as the low-hanging fruit on the waste/inefficiency tree. By marginal is usually meant treatments, technologies, or other procedures that are either useless or of a wastefully low probability of benefit.

But it is time to recognize that perhaps the most difficult puzzle in the control of costs is to learn what to do with marginal benefits. The essence of the difficulty is that (a) a marginal benefit from a population perspective may be decisively beneficial for some (statistically unknown) individuals, and (b) that individuals (and their physicians) can have radically different notions of what counts as a benefit.

Marginal benefits, moreover, can be of at least two kinds. One of them shows up in a class of treatments that are – often for many – health enhancing (hypertension or arthritis treatments) but where other efficacious treatments are available for the same conditions. The other kind occurs when there is life or death at stake, or some highly desired improvement bearing on a patient’s quality of life (some cancer treatments in the former case and some Alzheimer’s treatments in the latter), and with few or no available alternatives.

These distinctions become important in determining what to do about both kinds of cases. In the instance of health-enhancing but where (perhaps somewhat less) health outcomes can be had with alternative treatments, we might readily let cost considerations enter in. A marginal benefit for one treatment may seem self-evidently worth sacrificing for an (almost) identical health outcome with another one.

The matter will most likely be otherwise with treatments that directly affect survival or make a major contribution to quality of life. A number of cancer treatments, and Aricept and similar drugs for Alzheimer’s, all expensive, fall into that category. Some cancer drugs, for instance, improve overall survival for a short time only for a huge amount of money (Erbitux, $80,000 for 1.2 months additional survival time, and Avastin, $90,816 for 1.5 additional months).

The use of the drug Aricept is a good example of an expensive treatment (over $2,500 a year) that does not extend life expectancy but does seem to slow the progression of the disease for a short period (a few months). For a time Aricept was considered controversial, with the debate focused on whether it did in fact slow the progression. More recently, however, it has generally been accepted as a valid treatment in European countries and in the U.S. Medicare program.

A common description of its benefit is that it can have a small but statistically significant value in marginally slowing the loss of cognitive function and the rise of behavioral problems. In 2006 it was the seventh most prescribed drug in the Medicare program.

Are the cancer drugs and Aricept worth the large amounts of money spent on them? That question seems to me appropriate and necessary, but our culture and our health care system all conspire to reject it for serious consideration.

The most generic way this is done is to declare that life is priceless and even to pose such a question is immoral; and so also with the idea of rationing beneficial treatments. Considerations of cost should simply have no place in our reform calculus.

But there are more subtle ways that cost are sidelined in the reform debate. One of them is the powerful role of the pharmaceutical industry, also taken up in the New Old Age. By treating any consideration of cost as a threat to innovation, both the profit motive is protected (patents run out), and the American romance with endless medical progress is pandered to.

The drug industry spends millions of dollars lobbying Congress and marketing its products, and the latter is particularly important for drugs with marginal benefits. One interesting study found that, almost invariably, industry-sponsored research findings were rhetorically hyped far more than nonindustry results, and that difference was reflected in marketing techniques, especially in the media.

To be sure, the marketing always includes the proviso that one’s physician should be consulted about whether the drug is appropriate for the patient’s condition. But here is where the other subtle barrier to considering the cost of marginal benefits is raised. As the resistance to comparative effectiveness research has made eminently evident, industry and at least some important segments of the medical community want the doctor-patient relationship to remain free of any government interference.

The Senate Finance Committee has made clear that the research findings should not be used to establish practice guidelines or even to make treatment recommendations. In that context, there will be no grounds whatever for a physician or a patient even to resist rejecting a treatment with marginal benefits. They need only to want it. By casting the use of solid scientific evidence as optional if it comes from the government – the only institution with the resources to carry out expensive studies – the classic idea of medicine as a mix of art and science is rejected for policy purposes.

No less rejected is any feasible way to combat the waste and inefficiency brought about by treatments and technologies with marginal benefits, now turned into a private matter between doctor and patient. Almost all new technologies these days are marginal in their benefits. To deprive our society of effective means of coping with them seems to me a disastrous “reform” outcome. A potentially powerful way of controlling costs has been deliberately pushed aside.

Daniel Callahan is editor of the Health Care Cost Monitor.

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