Reflecting on cases from her own practice, a practicing oncologist recently suggested this in the Journal of Clinical Oncology: consider high price a “toxicity,” or adverse side effect, of an expensive drug for cancer, just like nausea, infections, or having one’s hair fall out are toxicities. Cancer doctors, especially in clinical trials, assess the severity of drug toxicities using an internationally-accepted, periodically-updated scale developed by the National Cancer Institute. On that scale, grades 1 through 4 reflect, respectively, mild, moderate, severe, or life-threatening adverse effects.
For high drug costs, the physician-author in question suggested something like the following to estimate the effects of a patient’s out-of-pocket cost burden:
- Mild: not spending money on a vacation, or seeking charity or drug company support, to be able to afford a recommended drug;
- Moderate: dipping into retirement savings, selling stocks, taking disability, or losing one’s job temporarily;
- Severe: permanent job loss, taking on debt greater than income, re-mortaging the house, being unable to pay for food or utilities;
- Life-threatening: having to sell the house, file bankruptcy, stop treatment because of inaffordability, or even considering suicide because of financial burden.
My first reaction to this was to disparage it as an attempt to ram the cost debate into the language of bedside medicine and biomedical research. But on brief further reflection, it makes sense as an attempt to grasp what the high cost of a drug might mean for a patient’s quality of life, and use that attempt to inform conversations with the patient about treatment options.
Now, it is commonly the case that a doctor’s assessment of how something might affect a patient’s quality of life is not the same as what the patient would say; the actual “patient reported outcome” must be matched with the “physician assessed” factor. But that could be discussed with the patient. And doing so would not, in itself, amount to “rationing at the bedside.”
The key comment from this doctor’s essay: “Looking back, would I have recommended different treatments to [my patients] if I was using a grading system for financial toxicity? Honestly, probably not, but I would have been more cognizant of their financial status…could have raised the issue of financial risk…helped them to anticipate and prepare for financial hardship…connect them earlier with community resources…[help them] more fully weigh their treatment options….”
In the meantime, pitched battles over prices are necessary and inevitable. I read where Gilead, maker of the $1000-per-day/$84,000-total-price drug Sovaldi, which is curative of hepatitis C, is working on an improved alternative that they probably would price even a bit higher, but at or below the total cost of existing drug treatments (which now include Sovaldi plus other drugs). Think on the order of $90,000-$100,000 for a cure. And the medical director of at least one insurer is saying, try about half that ($45,000). Sounds to me like the beginnings of a negotiation.