Costly Drugs Force Life-Death Decisions

Bottles of pills line the counter of Rebecca Dague's kitchen in Medina, Ohio, in this May 17, 2006 file photo. Dague takes an array of supplements in addition to the expensive drug, Erbitux, to treat her colon cancer. (AP Photo/Mark Duncan, File) (Mark Duncan - AP)

Employers and insurers are discreetly controlling costs through premiums, deductibles, co-payments, caps, and even outright exclusions. "Benefit costs would go through the roof if there were no considerations given to the costs," says Karen Ignagni, president of the trade group America's Health Insurance Plans.

Despite official denials, the federal Medicare program makes subtle cost evaluations, says Dr. William Maisel, a Boston heart specialist who chairs a federal committee on cardiac devices. "I think they are concerned about people using the term `rationing' or `withholding therapies,'" says Maisel, at Beth Israel Deaconess Medical Center.

One way to control costs, without saying "no," is to keep reimbursements low. For example, Medicare's $140,000 reimbursement last year for heart pumps is widely acknowledged as below-market.

"We can't say, `No,' explicitly. We say, `Yes, but,'" explains Peter Neumann, who runs a Tufts University center on medical cost-effectiveness in Boston.

Yes, but start with a cheaper drug, get prior authorization, or make a bigger co-payment.

Or, for the 45 million uninsured: Yes, but go to the emergency room and rely on charity for extended care. The nonprofit Patient Advocate Foundation reports that nearly half of its cases or requests for help involved co-payments last year, up from just 5 percent in 2002.

"If you've got a thick wallet or a full purse, you can get any care you want. If you don't, there's rationing for you," says former U.S. Health Secretary Joseph Califano, who later dealt with escalating health costs as a board member at Chrysler Corp.

"We're going to have to think very hard about how to provide some of these truly exotic treatments," he adds.

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Many now press for more systematic thinking about cost controls applied by insurers, hospitals, and policy makers. They say medical guidelines should more strongly steer older, sicker patients _ and other inappropriate candidates _ away from the most expensive treatments.

Cost-effectiveness analyses should be applied, they say. One common approach calculates the cost of a treatment for each year of life it saves. Many health economists view $50,000-to-$100,000 as a reasonable upper limit for what public and private insurers should pay.

Such calculations include adjustments for lost quality of life. For example, a heart pump is clearly less valuable if it puts a patient in the hospital for three of his last five months with a miserable infection.