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The values debate in health care.

Most developed countries face similar challenges in attempting to stem rising health care costs. The common forces driving utilization and costs include technological advancement, demanding consumers, and an aging population. The most elusive factor, however, is the role that social values play in shaping health care systems.

Health economists often fail to recognize that health care systems reflect social values, not just science and economics. In this country, stakeholders are often caught in the gap between what experts define as policy goals and options and what the public will accept. The loosening of managed care over the past decade is an example of the power of social values to circumvent policy and reshape the health care system. Consumers and the media rejected the concept of gatekeeper health maintenance organizations, despite an ability to constrain costs, because they value freedom of choice in all markets, including health care.

As Americans live longer with chronic illnesses, the definition of good health that can be financed through insurance has been dramatically expanded.

Coverage for drugs to treat erectile dysfunction illustrates how our perceptions of health translate into expectations that insurance should pay for costly drugs that aren't life-essential but can improve quality of life. Wellpoint was the first company to cover Viagra (sildenafil) for erectile dysfunction when there was a comorbidity. The social value issue, however, was not whether to cover Viagra, but how many pills to include in a 1-month supply.

Increasingly, similar challenges apply to coverage decisions for other "lifestyle" drugs--for which direct-to-consumer advertising create demand--as well as alternative therapies. Cultural values will continue to influence how government and insurers manage their resources in response to ever-changing definitions of health and illness.

The history of experimental high-dose chemotherapy with autologous bone marrow transplant (ABMT) illustrates how social values can overwhelm scientific evidence. ABMT was offered to late-stage breast cancer patients as a last-chance intervention. It was clinically unproven, but most health plans covered it in response to political pressure and to avoid lawsuits.

Health insurers spent more than $3.4 billion--a cost more than twice that of standard treatment--on ABMT. Ultimately, five major randomized trials showed that ABMT offered no survival advantage over standard-dose chemotherapy.

Americans desire unfettered access to the latest treatments, even if experimental and unproven. The pursuit of this value through the political and legal systems often favors the plaintiff because neither politicians nor juries are dispassionate. Courts and the media are tempted to disregard scientific evidence to demonstrate compassion for individuals and hope that an unproven therapy will work. Unfortunately, as the ABMT example shows, the results can be poor public policy, costly in both human and financial terms.

The challenge faced by legislators and policy makers is translating cultural values into viable national policy, even as these values shift to keep pace with social and technological change.

Value-driven transformation to an affordable, safe, evidence-based health care system is achievable if consumers can connect their personal involvement in their own health care decisions with protecting broader access to affordable coverage for all Americans. But it won't be easy to influence patient values.

The physician-patient relationship, however, affords physicians an excellent opportunity to enhance this process. Physician leadership at the office level may emerge as the essential ingredient to achieving our nation's health policy goals.


LEONARD D. SCHAEFFER is chairman and CEO of Wellpoint Health Networks Inc., based in Thousand Oaks, Calif.
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Title Annotation:Guest Editorial
Author:Schaeffer, Leonard D.
Publication:Internal Medicine News
Geographic Code:1USA
Date:Oct 15, 2004
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