Personal experience leads me to quibble, though, with one of his examples of wasteful care, which made cost-benefit decisions seem cost-free. He said, “If there’s a blue pill and a red pill, and the blue pill is half the price of the red pill and works just as well, why not pay half price for the thing that’s going to make you well?”
As it turns out, my own highly competent and socially responsible primary care physician some time ago prescribed generic Simvastatin to bring down my cholesterol. It didn't work well, though later conversation revealed that occasional 1-2 week gaps that I let slip between prescription refills may have been responsible. When a checkup revealed that my cholesterol levels had not improved, I asked her if I wouldn't do better with Lipitor. She said that Lipitor, which is not available generically, would cost me much more (and she might have added, cost the insurer much more), and "only" deliver perhaps a 5-10% advantage. (While writing this, I checked that estimate out, and found a Pfizer report touting a study result purporting to show a 14% advantage for Lipitor over competitors, including Simvastatin. This was a "report" that read awfully like a Pfizer press release on a site of dubious provenance, with no "about" section.)
Assuming that my doctor was roughly right about the 5-10% Lipitor advantage , this was exactly the situation that Obama sketched -- except that there was a genuine cost-benefit choice to be made. Would a modest improvement in drug performance be worth an additional $20/month to me - and God knows how much to the insurer? That's a very complex calculation; variables include my age, the extent to which my cholesterol numbers were worrisome, and my overall cardiovascular profile (e.g., a C-reactive protein test that yielded a good result); whether my insurer should have paid for that test is a whole other question). I am currently trying again with Simvastatin.
Were I on Medicare, would an empowered MedPac oversight panel making decisions about what treatments to fund approve prescribing Lipitor to me? Would the doctor have any incentive to say, 'first try taking your Simvastatin regularly'? And it would be nice if someone wouldmandate that my insurer allow me to buy a three-month's supply at a time, so I'd be likelier to refill on time.
Obama himself has pointed out in other contexts that bringing medical costs under control will ultimately entail more agonizing choices. Here is an April 28 exchange with David Leonhardt, foreshadowing the MedPac proposal:
Difficult choices notwithstanding, American health care practice is rife with overprescription of scores of tests, operations, drugs and other treatments of dubious value, or of value only a fraction of the times they are prescribed. Don't get my wife, a nurse midwife, started about amniocentesis, a procedure usually about as valuable as a trip to the Oracle at Delphi. Not to mention Caesarian sections, which at her hospital are performed on something approaching 40% of births.
Now, I actually think that the tougher issue around medical care — it’s a related one — is what you do around things like end-of-life care —
LEONHARDT: Yes, where it’s $20,000 for an extra week of life.
THE PRESIDENT: Exactly. And I just recently went through this. I mean, I’ve told this story, maybe not publicly, but when my grandmother got very ill during the campaign, she got cancer; it was determined to be terminal. And about two or three weeks after her diagnosis she fell, broke her hip. It was determined that she might have had a mild stroke, which is what had precipitated the fall.
So now she’s in the hospital, and the doctor says, Look, you’ve got about — maybe you have three months, maybe you have six months, maybe you have nine months to live. Because of the weakness of your heart, if you have an operation on your hip there are certain risks that — you know, your heart can’t take it. On the other hand, if you just sit there with your hip like this, you’re just going to waste away and your quality of life will be terrible.
And she elected to get the hip replacement and was fine for about two weeks after the hip replacement, and then suddenly just — you know, things fell apart.
I don’t know how much that hip replacement cost. I would have paid out of pocket for that hip replacement just because she’s my grandmother. Whether, sort of in the aggregate, society making those decisions to give my grandmother, or everybody else’s aging grandparents or parents, a hip replacement when they’re terminally ill is a sustainable model, is a very difficult question. If somebody told me that my grandmother couldn’t have a hip replacement and she had to lie there in misery in the waning days of her life — that would be pretty upsetting.
And it’s going to be hard for people who don’t have the option of paying for it.
THE PRESIDENT: So that’s where I think you just get into some very difficult moral issues. But that’s also a huge driver of cost, right?
I mean, the chronically ill and those toward the end of their lives are accounting for potentially 80 percent of the total health care bill out here.
So how do you — how do we deal with it?THE PRESIDENT: Well, I think that there is going to have to be a conversation that is guided by doctors, scientists, ethicists. And then there is going to have to be a very difficult democratic conversation that takes place. It is very difficult to imagine the country making those decisions just through the normal political channels. And that’s part of why you have to have some independent group that can give you guidance. It’s not determinative, but I think has to be able to give you some guidance. And that’s part of what I suspect you’ll see emerging out of the various health care conversations that are taking place on the Hill right now.
P.S. Leonhardt must have crowed tonight to hear the President adopt the lede from Leonhardt's 7/22 front page article, which framed the President's communication challenge as explaining to the American people re health care reform, what's in it for me? In his prepared remarks, Obama used the very words:
I realize that with all the charges and criticisms being thrown around in Washington, many Americans may be wondering, "What's in this for me? How does my family stand to benefit from health insurance reform?"See also:
Massachusetts Commission cuts the Gordian Knot on healthcare costs
Leonhardt seconds Gawande: put doctors on salary
Orzag hones in on doctors' incentives