What is it worth to see (or live)?

February 1, 2008

As society demands ever higher-quality care at lower costs deciding between the more inexpensive product or treatment and which is more effective will become the choice faced by patients and physicians.

Key Points

Today, hospital and medical bills following a severe illness might well exceed $6 million, as does the amount awarded by some juries in medical malpractice cases. And if we consider the cost of wrongful death, in one instance, the award for a LASIK case was $7.2 million.

These points raise the issue of how much we should-or our society can afford to-pay to save lives and prevent loss of vision. In an interesting article in Forbes, W. Kip Viscusi, PhD, of the Vanderbilt University Law School, discusses the dollar value that economists place on human life. According to Dr. Viscusi, the Environmental Protection Agency calculated that the lives of people aged more than 70 years are worth 37% less than the lives of those aged fewer years. Most government agencies, we are told, place the value of a human life at between $5 million and $7 million. To offer one perspective, the cost associated with cleaning up some of the "Superfund" toxic waste sites equates to billions of dollars per expected case of cancer prevented.

Pharmacoeconomics is the branch of economics that applies cost-benefit, cost-effectiveness, cost-minimization, and cost-utility analyses to compare the economics of different pharmaceutical products or to compare drug therapy with other treatments. It seems to me that, as our society demands that we provide ever higher-quality care at lower costs, we are going to need pharmacoeconomic analyses to help us understand which therapeutic option is most cost-effective.

Pretty much during my career in medicine, if a new drug is a little bit better (say 10%) and costs 10 times as much as the previous drug, American physicians will prescribe the new drug without thinking twice about it. I have residents and faculty in my department who assert that the cost of therapy never should be considered as a factor in recommending treatment to a patient. This is a luxury that we may not be afforded much longer.

With anti-vascular endothelial growth factor agents for macular degeneration, a striking (perhaps 40-fold) difference in cost is associated with on-label ranibizumab (Lucentis, Genentech) versus off-label bevacizumab (Avastin, Genentech). If studies that are under way show that the two agents give identical outcomes, then, presumably, ophthalmologists owe it to society to use the less-expensive drug. If, hypothetically, the risk of stroke with the less-expensive drug is slightly higher, should we still opt for the less-expensive version? How much greater does the risk of stroke need to be to alter our decision-making? In this hypothetical situation, should doctors make the decision, or should we place patients in the position of having to choose for themselves and possibly accepting a greater risk of stroke in return for a lower cost of treatment?

We probably will be faced with answering questions such as these sooner rather than later.

Peter J. McDonnell, MD director of the Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, and chief medical editor of Ophthalmology Times. He can be reached at 727 Maumenee Building, 600 N. Wolfe St., Baltimore, MD 21287-9278 Phone: 443/287-1511 Fax: 443/287-1514 E-mail: pmcdonn1@jhmi.edu

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