APRIL 17, 2014, Courtesy The New York Times
Saying they can no longer ignore the rising prices of health care, some of the most influential medical groups in the nation are recommending that doctors weigh the costs, not just the effectiveness of treatments, as they make decisions about patient care.
The shift, little noticed outside the medical establishment but already controversial inside it, suggests that doctors are starting to redefine their roles, from being concerned exclusively about individual patients to exerting influence on how health care dollars are spent.
"We understand that we doctors should be and are stewards of the larger society as well as of the patient in our examination room," said Dr. Lowell E. Schnipper, the chairman of a task force on value in cancer care at the American Society of Clinical Oncology.
In practical terms, new guidelines being developed by the medical groups could result in doctors choosing one drug over another for cost reasons or even deciding that a particular treatment — at the end of life, for example — is too expensive. In the extreme, some critics have said that making treatment decisions based on cost is a form of rationing.
Traditionally, guidelines have heavily influenced the practice of medicine, and the latest ones are expected to make doctors more conscious of the economic consequences of their decisions — even though there is no obligation to follow them. Medical society guidelines are also used by insurance companies to help determine reimbursement policies.
The society of oncologists, alarmed by the escalating prices of cancer medicines, is developing a scorecard to evaluate drugs based on their cost and value, as well as their efficacy and side effects. It is expected to be ready by this fall.
And the American College of Cardiology and the American Heart Association recently announced that they would begin to use cost data to rate the value of treatments in their joint clinical practice guidelines and performance standards.
Some doctors see a potential conflict in trying to be both providers of patient care and financial overseers.
"There should be forces in society who should be concerned about the budget, about how many M.R.I.s we do, but they shouldn’t be functioning simultaneously as doctors," said Dr. Martin A. Samuels, the chairman of the neurology department at Brigham and Women’s Hospital in Boston. He said doctors risked losing the trust of patients if they told patients, "I’m not going to do what I think is best for you because I think it’s bad for the health care budget in Massachusetts."
Doctors can face some stark trade-offs. Studies have shown, for example, that two drugs are about equally effective in treating an eye disease, macular degeneration. But one costs $50 a dose and the other close to $2,000. Medicare could save hundreds of millions of dollars a year if everyone used the cheaper drug, Avastin, instead of the costlier one, Lucentis.
But the Food and Drug Administration has not approved Avastin for use in the eye, and using it rather than the alternative, Lucentis, might carry an additional, albeit slight, safety risk. Should doctors consider Medicare’s budget in deciding what to use?
Some insurers and state Medicaid programs are now also saying that a highly effective new drug for hepatitis C, Sovaldi, from Gilead Sciences, could lead to an immense increase in spending because so many patients will want to use it, at a cost of $84,000 per course of treatment.
Some of them are hoping that, to save money, only more seriously ill patients will be treated. But Dr. Donald M. Jensen, director of the center for liver diseases at the University of Chicago, said some patients with earlier disease have symptoms like fatigue and would benefit from the drug. "I think ethically we are just worried about the patient in front of us and not trying to save money for the insurance industry per se, or society as a whole," he said.
Still, some analysts say that there is a role for doctors to play in cost analysis because not many others are doing so.
"In some ways, it represents a failure of wider society to take up the issue," said Dr. Daniel P. Sulmasy, professor of medicine and ethics at the University of Chicago.
Generally, Medicare is not supposed to consider cost effectiveness in coverage decisions, and other government attempts to do so are susceptible to criticism as rationing. Insurers do perform cost analyses, but they also risk ire from patients and doctors.
The cancer and oncology societies are not the only ones considering costs. A review last year of clinical guidelines issued by 30 of the largest physician specialty societies found that 17 of them explicitly integrated costs. That appeared to be an increase from 2002, when a different review had found more limited use of economic analysis.
Also, in recent years, as part of a campaign called Choosing Wisely, many medical societies have submitted lists of the top five procedures, tests or products to be questioned because they are considered wasteful.
The cardiology societies say that the idea that doctors should ignore costs is unrealistic because they already have to consider the financial burden placed on the patient, if not society. "Protecting patients from financial ruin is fundamental to the precept of ‘do no harm,’" the societies wrote in their paper outlining the new policy.
Still, the groups said that value and resource use had been explicitly excluded from formal consideration in their practice guidelines. And that has been true of some other guidelines as well.
Dr. Schnipper, who is also chief of hematology and oncology at Beth Israel Deaconess Medical Center in Boston, pointed to guidelines that the oncology society issued in 2011 on preventing vomiting caused by chemotherapy. For certain patients, the guidelines recommend the drug palonosetron, sold by Eisai as Aloxi, which is more effective but also much more expensive than similar drugs. While the full guidelines contain a table listing the prices of various drugs, there is no explicit discussion about the cost trade-offs in the recommendations.
Hepatitis C guidelines issued in January by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America recommend the new drug Sovaldi with no mention of its cost.
Dr. Steven D. Pearson, a visiting scientist in the ethics department at the National Institutes of Health, said the move by some societies to incorporate economic analysis "heralds an important shift in the way doctors in America are talking about cost and value."
He said that having societies do such evaluations was better than having a doctor make such trade-offs while treating an individual patient, which is sometimes called bedside rationing.
Still, it is unclear if medical societies are the best ones to make cost assessments. Doctors can have financial conflicts of interest and lack economic expertise.
The cardiology societies, for instance, plan for now to rely on published literature, not commission their own cost-effectiveness studies, said Dr. Paul A. Heidenreich, a professor at Stanford and co-chairman of the committee that wrote the new policy.
They plan to rate the value of treatments based on the cost per quality-adjusted life-year, or QALY — a method used in Britain and by many health economists.
The societies say that treatments costing less than about $50,000 a QALY would be rated as high value, while those costing more than $150,000 a QALY would be low value.
"“We couldn’t go on just ignoring costs," Dr. Heidenreich said.