Can Doctors Choose Between Saving Lives and Saving a Fortune? The New York Times

“To understand something about the spiraling cost of health care in the United States, we might begin with a typical conundrum: Imagine a 60-something man — a nonsmoker, overweight, with diabetes — who has just survived a heart attack,” Siddhartha Mukherjee writes over at The New York Times. “Perhaps he had an angioplasty, with the placement of a stent, to open his arteries. The doctor’s job is to keep the vessels open. She has two choices of medicines to reduce the risk for a second heart attack. There’s Plavix, a tried-and-tested blood thinner, that prevents clot formation; the generic version of the drug costs as little as 25 cents a pill. And there’s Brilinta, a newer medicine that is also effective in clot prevention; it costs about $6.50 a pill — 25 times as much. Brilinta is admittedly more effective than Plavix — by all of 2 percentage points. In a yearlong trial of 18,600 patients, 10 percent died from vascular causes, heart attack or stroke on Brilinta, while about 12 percent did on Plavix. Should the doctor prescribe the best possible medicine, assuming that the man has private health insurance that will pay the bulk of the costs? Or should she try to conserve health care costs by prescribing the cheaper medicine that is nearly as good? And consider this: If the cost to you was the same — you have maxed out your co-pay and will end up with the same out-of-pocket expenditure — would you agree to take the slightly inferior drug to benefit the system as a whole? You’ve just had a heart attack, for God’s sake. You pay thousands of dollars for health insurance. Is it fair to ask you to bear the slightly increased risk to enable some broader social good? ‘We thought about this nearly every day when discharging patients from the cardiology unit,’ Dhruv Khullar, a newly minted hospital attending, told me. ‘Some of us believed that a doctor’s job is to deliver the best possible care, period. Others argued that doctors should aim to find some balance between medical benefit, financial cost and social responsibility. It’s the kind of question that we aren’t really trained to solve. Are costs something that an individual doctor should do something about? What is a doctor supposed to do?’ I returned repeatedly to the basic elements of Khullar’s quandary  … while reading a new study that hopes to solve the riddle of health care costs in the United States. As the authors, Irene Papanicolas, Liana Woskie and Ashish Jha, lay it out, the United States is a sore-thumb outlier among 11 wealthy nations in medical spending. We spend 18 percent of our G.D.P. on health care, while Australia, Canada, Denmark and Japan seem to make do with about half that amount. Yet life expectancy in the United States is the lowest in the group, and infant mortality is the highest. Our out-of-control prices have a stifling effect on the economy. Companies that pay a portion of health insurance for their workers may find themselves burdened by cost. … Why are we spending astronomically more for health care that performs worse, on aggregate, than care in most other comparable nations?” Siddhartha Mukherjee,  “Can Doctors Choose Between Saving Lives and Saving a Fortune?” The New York Times.