A bit over a year ago, two health-care researchers took to the New England Journal of Medicine and challenged each care specialty to come up with five treatments that could be eliminated or modified to cut costs without hurting patients. In yesterday’s edition of the journal, two cancer specialists were the first to respond. Merrill Goozner summarizes their recommendations:
1) Only use testing and imaging where “benefit has been shown”;
2) Limit second-line and third-line treatments to metastatic cancer to sequential monotherapies for most solid tumors. “Patients will live just as long but will avoid toxic effects. ... Society will benefit from cost reductions associated with less chemotherapy, fewer supportive drugs, and fewer toxicity-associated hospitalizations”;
3) Don’t give chemotherapy to people when their cancer has made them so weak that a positive response is highly unlikely;
4) Lower chemo doses to eliminate the routine use of drugs that replace the white blood cells destroyed by toxic chemo drugs; and
5) Stop treating patients if they haven’t responded to three different drug regimens — unless they are enrolled in a clinical trial actually testing the fourth regimen.
Helpfully, Goozenr also summarized the Wall Street Journal editorial page’s likely response:
1) It’s rationing that abrogates physician autonomy;
2) It’s rationing that prevents individual choice in evaluating the trade-offs between benefits and risks;
3) It’s rationing that denies very ill patients hope;
4) It’s rationing that puts cost ahead of best practices; and
5) Did I mention that it’s rationing?
My hunch, however, is that the only thing that’s really rationing is the thing your doctor tells you is rationing. If he can’t start you on a fourth drug regimen because the insurance won’t pay for it or the government says no, that’s rationing. If he doesn’t start you on a fourth drug regimen because he doesn’t think it’ll help and the focus now has to be on making you comfortable and trying to get you into a clinical trial, well, that’s just good care.