The Cost of Living

The answers aren't easy:

The sky-high cost of staying alive, by Jeff Donn, The Associated Press: Dying of lung cancer, Carolyn Hobbs tried a new biotechnology drug that produced an unanticipated side effect: acute sticker shock.

She was waiting for her second treatment in a hospital ..., when someone from the business office marched in. Her share, she was told, would cost more than $18,000, since the drug wasn't insured for her type of cancer. How to decide? ...

Maybe this new drug, Erbitux, could extend her life by a small fraction, but she wouldn't be cured. "She was just very frugal, and she said it wasn't worth it," her husband, Larry, remembers. So she refused the treatment.

More patients are confronting this wrenching decision, as the latest generation of pricier cancer drugs and heart implants stretches out the final months of advanced disease. Is the chance for several more months of life — maybe a year or more with luck — precious enough to spend a small fortune? ...

"People still have an underlying belief that there's an infinite amount of resources that can be invested in health care," says Dr. Harlan Krumholz, a Yale University heart specialist... "But I think we're coming to a realization that we're going to need to confront these issues explicitly."

Who gets what? Within the past decade, an array of expensive new treatments has given some patients their first real fighting chance against common diseases once routinely called "terminal." ... Some of these therapies, such as the biotech drug Gleevec for leukemia or implanted defibrillators for some heart problems, can work wonders.

The trouble with many treatments, though, is that average patients gain only several more months of life... A lucky few may survive for years. Faced with a lethal disease, more than a third of Americans now would want "everything possible" done to save their lives, up from just over a fifth in 1990, according to ... the Pew Research Center...

"It's better to pay the money than sleeping with the worms," said Jake Rogers, 62, of Chicago, referring to his implanted left-ventricular assist device. His doctors implanted a second one in June, when his first wore out after 15 months.

Yet this kind of care costs several times more than the older treatments it supplements or replaces. A mechanical heart pump can cost more than $200,000, with hospital care. A last-resort cancer drug can cost up to $50,000 a year — if patients survive that long — but insurance would typically pick up at least two-thirds.

Federal safety regulators evaluate only if drugs or devices work, not how well they work for their prices. And Medicare, which insures about 80 percent of dying Americans, makes no acknowledged evaluation of cost in deciding what to cover. Its coverage umbrella sets a standard for private insurers. ...

De facto rationing Yet choices are being made every day, case by case. Some insurers refuse to cover a treatment. Doctors send patients home to die, sometimes out of mercy. Some patients say enough is enough.

Employers and insurers are discreetly controlling costs through premiums, deductibles, co-payments, caps and even outright exclusions. Despite official denials, the federal Medicare program makes subtle cost evaluations, says Dr. William Maisel, a Boston heart specialist...

"I think they are concerned about people using the term 'rationing' or 'withholding therapies,' " says Maisel... One way to control costs without saying "no" is to keep reimbursements low for an expensive treatment. ...

Changes backed Many press for more systematic cost controls by insurers, hospitals and policy makers. They say medical guidelines must steer older, sicker patients — and other inappropriate candidates — away from the most expensive treatments. ...

One common approach calculates the cost of a treatment for each year of life it saves — with an adjustment for suffering and side effects. Many health economists view $50,000 to $100,000 as a reasonable upper limit.

Heart pumps, which were first used as a temporary bridge to a heart transplant and then approved as regular implants in 2003, cost between $500,000 and $1.4 million per year... Even one of their pioneers, Dr. Eric Rose at Columbia University, concedes that would make their value "more than challengeable," but he expects improvements. ...

But even some doctors worry that too many patients merely spend, suffer and die. Doctors, says University of Pennsylvania heart surgeon Dr. Michael Acker, should keep away from "high-tech, expensive technology just to postpone the inevitable."...