Money for Nothing
By Michael J. Katin, MD
"Now look at them yo-yo's, that's the way you do it"
Mark Knopfler and Sting, from the album "Brothers in Arms," 1985
The next wave of professional organization meetings is approaching, starting with the AUA May 8-13, ABS May 13-15, AFROC May 24-26, ASCO June 5-8, and ASTRO October 3-7. The character of each of these sessions has changed substantially over the past ten years, with presentation of breakthrough technology which everyone wants to be able to make available, but also with the realization that it might be impossible to pay for this. What's the difference between this and going to a boat show? At least you can usually get by without a boat.
In addition to the lag time from the FDA's approval of a drug or treatment until a system is worked out for reimbursement, there's also the problem of awaiting approval of drugs or techniques for new indications. Added to this, of course, is the view of cancer treatment as a necessity, with the expectation that an insurer rather than the patient should pay for this. At the start of the Clinton Administration the attitude was that a system needed to be set up to guarantee medical care to all Americans. Unfortunately this effort fell upon hard times.
Contrast this to other commodities considered essential. I would dread the consequence of not promptly paying a water and sewer bill . Usually there are sources for food to be available at low or no cost, although sometimes dietary restrictions may make this problematic . There is, however, one "necessity" that we will find a way to buy regardless of the price.
Gasoline prices rose 30.1% during 1999. This caused distress in the economic community with calls for intervention to make the United States less dependent on foreign oil and for more effort in developing energy-efficient vehicles. Over 5 years there's not much to show for this and even the introduction of hybrid vehicles will not make much of an impact.
The secret may be that when the price goes up, the desirability goes up as well. Whereas previously it was no problem to drive into the gas station and fill up for $1.38.9 per gallon, we are now willing to line up at the only gas station in town that sells at $1.81.9 per gallon, and if it's too crowded, to go across the street to buy it at $1.88.9. I haven't noticed anyone making a conscious decision to skip going to the nearest Turtle Stop or On the Run for cigarettes or beer. People seem to be driving as much as ever, and the demand seems to keep going up rather than down as the price increases.
This could possibly be the solution to funding for medical care. In 1979 people were panicking when the price of a gallon of gasoline went over $1.00, and now they can't buy it fast enough when it's nearly twice that. Our error has probably been by being apologetic for the high price of technology and pharmaceuticals (of course, our professional charges have always been fair). If AstraZeneca announces that the price of Iressa will probably increase by 100% over the next year, maybe there will be a stampede to get it regardless of the indications. Maybe if there is publicity that IMRT will become more expensive to carry out because of maintenance, depreciation, and the need for software and hardware upgrades and maintenance, no one will think it rational to consider reducing reimbursement. If that doesn't work, ASCO and ASTRO could consider an alliance similar to OPEC to direct the production and availability of anticancer treatment. Most cancer drugs and many technical treatment components are made by multinational companies anyway, which would get around the charge of domestic price-fixing. When the availability of cheap gasoline diminished, there were attempts to promote production in the United States to eliminate dependence on foreign oil, and objections from environmentalists and others kept that from developing. We could anticipate that similar forces would reduce the ability of the United States to become independent in cancer treatment modalities, at least once Varian moves to Mexico.
This is, of course, nothing more than whimsy. Payment for advanced treatments for cancer will continue to be a battleground, and our specialities will continue to be caught in the middle and will try to stay objective until, of course, we're assessed an energy surcharge to help pay for the expense of patients' driving in for treatment.
Maybe I should open a Turtle Stop.