When a $50 cure is just as good as a $2,000 one
I’m a doctor with a miracle drug. Three of them, in fact. Their names are Avastin, Lucentis and Eylea. I use them to treat the No. 1 cause of blindness in Americans over 65: wet age-related macular degeneration (AMD). Calling them a miracle is no understatement. If your doctor delivers the unlucky news that you’ve developed wet AMD, it means blood vessels under your macula have started to leak or bleed, robbing you of the sight you rely on to read books, see faces, watch TV or drive.
Enter the miracle drugs — eye injections that limit those leaking submacular vessels, giving us our first treatment capable of bringing vision back. But somehow, these drugs have become among the most controversial in all of medicine.
All three treat wet AMD very effectively. Their most significant difference is cost. Lucentis and Eylea cost approximately $2,000 and $1,850 per dose, respectively. Avastin? Only $50.
Medicare covers them all, so retina doctors and their patients are free to choose whichever medication they wish. A recent survey of our field showed that 64.3 percent of us choose Avastin as our first-line drug. Yet about 35 percent of retina specialists continue to use the expensive medicines as their first treatment of choice. Why?
Most likely, because they feel these drugs are better than Avastin. After all, we’re taught to adhere to the ethical duty to “treat patients the way we’d treat our mothers or ourselves,” right? That’s a mental check of ethics I employ during virtually every patient visit, every single day. But what if, in addition to an ethical duty to do what we feel is best, we also had an ethical duty to recommend the most cost-effective care?
This isn’t the way it works now. No one questions that Avastin is by far the most cost-effective choice. But I think doctors who choose Lucentis and Eylea do so because they feel any perceived benefit, no matter how small, obligates them to do so. This is what they taught us in medical school, after all. But in a health care system with limited resources, the decision to use a medicine that costs $50 or an alternative that costs 40 times more has an enormous impact on our collective future.
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Avastin is prepared by compounding pharmacies and does not come straight from the company itself. Using Avastin is considered “off-label,” since Genentech did not seek FDA approval for its use in the eye.
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I believe doctors should contemplate a new ethical duty: to spend health care dollars cost-effectively. Our resources are limited and health care costs continue to escalate. Doctors should remain free to prescribe Lucentis and Eylea; but, in most cases, we can fulfill our ethical duty to both patients and society by recommending the most economical choice.
Some physicians and patients may fear that these ideas threaten our autonomy. I think if we do not each begin to seriously consider the impact of our decisions on the health care system as a whole — if we do not try to contain costs where it is in our power to do so — it won’t be long before our autonomy truly is in peril.
http://www.startribune.com/when-a-50-cure-is-just-as-good-as-a-2-000-one/361625411/
Andrew Lam is a retinal surgeon, an assistant professor at the Tufts University School of Medicine and the author of “Saving Sight.”
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