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Medical progress raises a question: What's life worth?

Published August 13, 2006

Dying of lung cancer, Carolyn Hobbs tried a new biotechnology drug that produced a side effect she didn't anticipate: acute sticker shock.

She was waiting for her second treatment in a hospital near Denver less than two years ago, 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?

In her six decades, she had shared in a long marriage, raised three children, worked in a nursing home, painted as a hobby - and wasn't ready to leave it all behind. But she was also a careful spender who sometimes returned new clothes to the store, deciding she didn't really need them.

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? Extraordinary care for dying patients can make for inspiring medicine, but its extraordinary costs make it an increasingly debated choice to promote public health.

* * *

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."

These treatments include biotechnology drugs that home in on cancer and mechanical implants that help the heart pump blood. Some of these therapies, like 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, studies have found. A few might 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 about a fifth in 1990, according to a poll by the Pew Research Center for the People and the Press.

"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 as much as $50,000 a year - if patients survive that long - but insurance would typically pick up at least two-thirds.

Yet the average patient in the best medical test so far lived less than nine more months.

Federal safety regulators evaluate only whether 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.

* * *

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 outright exclusions. Despite official denials, the federal Medicare program makes subtle cost evaluations, said 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,' " said Maisel, at Beth Israel Deaconess Medical Center. One way to control costs without saying "no" is simply to keep reimbursements low for an expensive treatment.

Private insurers often say yes - but start with a cheaper drug, get prior authorization, or make a bigger co-payment. 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. Or, for the 45-million uninsured, it's, yes, but go to the emergency room and rely on charity for extended care.

"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," said former U.S. Health Secretary Joseph Califano.

* * *

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.

Dr. Barry Straube, who heads the Medicare unit that decides what to cover, said "it would be helpful in setting priorities when we have limited budgets to look at cost-effectiveness."

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.

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

[Last modified August 13, 2006, 02:24:58]

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