Monday, December 8, 2014

Low hanging fruit in containing health care costs: the case of Lucentis and Avastin.

This morning's New York Times carries a wonderful illustration of one of the cardinal differences between the culture of healthcare in Israel and that in the US.  Katie Thomas and Rachel Abrams detail the odd history of Lucentis and Avastin, both effective drugs for macular degeneration, but with the difference that Lucentis costs $2000 per dose compared to $50 for Avastin.  Despite this massive difference in cost and multiple studies showing no clinical advantage for Lucentis over Avastin, many ophthalmologists, particularly those receiving industry payments, continue to prescribe Lucentis.  The cost to the Medicare program:  an extra $1 billion per year. Medicare, of course, has been barred by Congress from negotiating drug prices.  Pharmaceutical representatives quoted in the story express their belief in the importance of the ability of each physician to choose which drug to prescribe free from interference based on cost.  

In Israel, each year the national health system reviews the basket of covered health services including medications.  In 2009, the committee charged with this work considered the evidence and refused to cover Lucentis on the grounds that it had no advantages over Avastin, which was already available.  Such a decision making process does not exist in the US for patients covered by Medicare or other fee for service plans, although it does exist within HMOs.  This means that there is no national body in the US to review the pros and cons of medications and decide which have benefit that justifies their cost.  Ostensibly this is because we in the US highly value physician autonomy and the ability of each physician to choose the best treatment for an individual patient, as well as because we oppose any kind of rationing.  Yet that $1 billion we spend yearly is ultimately a decision about rationing something -- if not medical care, then schools, food stamps, or some other piece of the budget.  And of cource Lucentis is just one medication, one piece of the larger health care puzzle.

Speaking with Israeli physicians about the drug basket approach, it's clear to me that these are very difficult decisions, but ones that are made attempting to weigh the pros and cons of each item with the overall goal of improving the health of the population.  Decisions in the US might be easier, given the much high overall level of spending, but still few of us would choose to spend a billion dollars without any expectation of benefit.