Should all patients should have access to all treatments, regardless of their cost?
I have heard people say that most things are for sale. Even if a given object does not have a “for sale” sign on it, if you offer to pay well beyond its face value, most owners will be happy to part with the item. While I have never desired any particular thing so much or had the means to buy an item in this manner, I can understand the concept.
This principle generally refers to material objects, but can it also refer to health care? If you have unlimited means, can you obtain a treatment that will provide a cure in all cases? It is obvious to those of us in the medical profession that the answer is no. Just consider the example of Steve Jobs, who had unbelievable wealth and access to the best available medical care, but was still unable to halt the ravages of cancer.
How about looking at this issue from a slightly different angle: Should those with great personal wealth be able to access medications or procedures that will benefit them but that are beyond the financial reach of poorer patients with similar health conditions? Currently, our health care model does not generally differentiate between these 2 types of individuals. Quality health insurance plans generally provide care regardless of price. In fact, many patients do not even know what most health care treatments cost. They pay a co-pay or for a percentage of services, and then allow the health care provider and pharmacy benefit manager to negotiate payment for the rest.
Insurance companies might make accessing a given medication or procedure difficult by requiring prior approvals and paperwork, but most people are able to get the care they want if they follow the appropriate step-wise therapy and the treatment in question has shown benefit. Even though most people do not own a Ferrari or sleep in the Four Seasons while they vacation, they expect to have an analogous level of health care, and the model is currently set up to deliver just that. For those with good insurance, health care has largely become a right and not a privilege.
As medical science continues to advance, and we expand our understanding of diseases and the body, we are able to design new treatment modalities that can dramatically impact health. Whether through pharmacogenomics, better drug development, improved diagnostics, or other advances, we are increasingly able to tailor treatment plans and regimens for the individual patient.
For example, take hepatitis C. The backbone of therapy for this condition has been peg-interferon and ribavirin, with the addition of boceprevir and telaprevir for certain genotypes. While the hepatitis C virus genotype of the patient directs therapy options and duration, a successful regimen generally depends on maintaining adherence over a lengthy period of at least 24 weeks and sometimes much longer. These medications also have significant side effects, which can impair treatment. In addition, peg-interferon is injectable, which further affects adherence.
What if the hepatitis C regimen could be condensed into a treatment period of just 12 weeks, during which patients would only have to take a single tablet per day with minimal side effects, yielding a cure rate of greater than 90%? With the recent approval of sofosbuvir and some emerging data, this could become a reality. The only catch is that a 3-month course costs more than $100,000. Can we afford to offer this treatment to all the patients who may benefit from it?
More treatments that represent significant advances in care but come with similarly hefty price tags are most likely just around the corner. Treatments for conditions such as cancer, HIV, and cystic fibrosis that can benefit many people, even our loved ones, may be next. But is there a cost threshold at which we will need to draw the line on access for all? We cannot afford our current system of health care, and I can only imagine what the future will bring. Perhaps we need to start considering whether all patients should have access to all treatments, regardless of price, or whether some treatments should only be available to those who can pay for them out of pocket.
I would be interested to hear your perspectives on how best to manage this situation. You can let me know what you think by email at email@example.com.