What am I Worth?

I hope all had a wonderful Christmas celebration yesterday (or for those who don't celebrate Christmas, a wonderful and relaxing day off)! We are entering the last week of 2011 and I wanted this post to reflect some of the struggles that I'm having with the big issues in health and wellness both personal and societal. One aspect of this crystallized yesterday as I was washing dishes and having a wonderful discussion about the cost of healthcare. The bottom line comes in when making payment decisions on a macro level, what is the life of a person worth? What am I worth in dollars and cents support from the government and other payors? I've done a lot of work over the last six months with investigational cancer drugs. Some of them are pretty far into the future and some are relatively close to market. All of the compounds show promise in controlled clinical trials, but we clinicians know that practice life is far from the controlled trial environment of drug development. This is one of the reasons why drugs perform less well in actual practice than they do in research trials. Once a compound is approved in the U.S. a prescriber can use it in any way they deem appropriate given their level of understanding of the compound (think Avastin or NovoSeven for example). The other problem is the euphemisms used as markers for success in cancer trials (e.g., disease free interval, progression-free survival, objective response rate, clinical benefit rate, time to treatment failure, invasive disease free survival, overall survival). Saddled by a lack of curative compounds, cancer drugs are evaluated on their ability to keep the disease below our crude level of detection. Many of the new compounds I've reviewed are not replacing anything, they are additive to what is already being used - so they are adding significant cost to the equation. The compounds in question cost many thousands of dollars each month (up to $10,000). If, as one compound I reviewed last week, an agent on average prolongs overall survival by 4 months - is that a "good" investment? It begs the question, what am I worth? Not just to my family and friends, but to society as a whole and to those who will share the burden of my treatment. Most drug manufacturers have patient assistance programs to offset some of the cost burdens of these therapies, but as a society we are coming up against a most difficult dilemma. No one wants to use the "r" word (rationing) but the reality of the cost burdens of these new targeted therapies is too big to ignore. The Center for Medicare and Medicaid Services (CMS) is already dealing with programs that are impossible to maintain financially (due to poor management over the last decades), but those costs to maintain are increasing at an unsustainable rate. John Q. Public is asked to fund these programs from payroll taxes, but no one ever envisioned a cost scenario like what we are currently living. What is my life worth? Huge societal dilemmas like this one can not be answered easily or gently or quickly. It takes great courage to open the debate and dialogue on how to even begin to approach somehting of this magnitude. One has to be able to suffer under the slings and arrows of rhetoric (think "death panels") and come out the other side with self intact. We need to be able to approach these large issues from a place of openess and honesty - love for each other. On one hand, each human life is precious beyond measure and should be nurtured in ways to help it meet its intended reason for being created. However, we can not afford to spend $10 million on 7 billion...there has to be some rationality and social justice. At the end of the year, I offer this musing to begin the dialogue with you on how we come to grips with huge truths. I don't have answers, and I struggle daily with these questions. Together, however, we can find a way to deal with that which confronts all of us. Peace for the journey, Dan