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Starve them or shoot them.

Starve Them or Shoot Them

It finally happened. Two weeks ago a senior vice president from a major pharmaceutical company called me up.

"Lee," he said, "I have a problem I need your advice on. It's sort of a cost and quality problem," he said hesitatingly, "and I don't quite know what to do about it. I thought with your knowledge...."

"Fine," I said, nestling into my chair. "Let's hear it."

"Well," he said, "the good news is that we've got this new drug that's just great for prostate cancer. The literature suggests that patients live about seven months longer when it's used in combination with several other old-line therapies."

"Sounds great," I said. "What's the problem?" "The problem is the cost," he said. "Ah," I thought. "Here we go again. Another high-priced drug that the insurers will refuse to pay for, because it's not on the FDA label as an indication for use." But I was wrong.

"Actually," he said, "We've priced it pretty reasonably. In fact, month for month our therapy is lower in cost than the current therapy. So I've presented a proposal to three different insurers and, the upshot is, they don't want to pay for it."

"I don't get it," I said, hoping I didn't.

"The deal is this," he said. "The total cost of our treatment is higher, because the patient lives longer."

Now I've thought about this conversation for the last two weeks and mulled over our options. As I see it, we have four standard options:

Option #1: Accept defeat. This option used to be the last option on the list, but as I see more and more medical oncologists who are exhausted from fighting the same battles over and over again, I can see it becoming the #1 option. Sometimes the dragon wins.

Option #2: Prepare to do battle. This is the option where we all put on the family armor (which is badly dented from multiple battles with dragons from the Office of Technology Suppression), rally the troops, remount our horses, and charge the monster again.

Option #3: Let George do it. This option is a favorite of academics. Basically, it means that we moan and complain, but stay as far away from the front line of battle as possible. This option essentially is slightly different from #1, because we know that somebody else is going to take care of it and we just don't have the time.

Option #4: Appeal to a higher authority. This is where the...lobbyists set up another meeting with HCFA officials to cure a problem that HCFA has nothing to do with. In other words, the armada attacks the wrong monster.

To these standard options, I believe we should add another, perhaps more relevant, option.

Option #5: Starve them or shoot them. All monsters have a source of nourishment. I think it's time to turn our attention to that source of food. In the land of insurance coverage, the monster gets fed by purchasers of care. These purchasers feed insurance companies with premiums and money. They think that feeding them premiums guarantees them protection. I believe we have to tell these unwary dragon feeders that the dragon has figured out that the fewer people he has to protect, the easier his job. In fact, the dragon gets to hoard all of his gold which, let's face it, isn't worth as much as it used to be, and which has been steadily declining ever since other dragons showed up to protect other kingdoms.

So, let's cut out their food supply. In my opinion, that fifth option--informing the dragon's feeder, involving the purchasers of care, rating the cancer benefits in insurance plans, and spreading the news--holds the best long-term hope for cancer patients.

Because we're in a hurry, we should also consider just shooting them. The idea that living longer is a waste of resources is a national scandal! It should be the headline in the Times, the Post, and the Journal--something to the effect of "Insurance Dragons Turn on the Folks that Feed Them." Like I said, starve them or shoot them.
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Title Annotation:insurance coverage for drugs
Author:Mortenson, Lee E.
Publication:The Hastings Center Report
Date:May 1, 1989
Previous Article:Haven't got a prayer.
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