Where is the limit?

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Imagine you are a doctor and you have just diagnosed a patient with a rare, terminal disease. There is a drug on the market, but the patient’s health insurance does not cover this because it costs €500.000 per year. Are you going to tell your patient he is not worth the money and let him die?

It is a controversial subject: the maximal cost for a certain drug or procedure that could save a patient’s life. If you were to ask a lay person, odds are you will get an answer like ‘a life does not have a price’ or ‘there should not be a limit’. A left-wing politician might agree to this. It is also often in the news: insurance companies that do not want to cover expensive drugs anymore. The logical question arises how to determine this limit, and who should have the power to set it.

Maximum costs when saving lives are not unusual. Comparing costs and benefits happens in an infrastructural setting all the time: whether or not a dangerous intersection ought to be reconstructed or not. Business as usual. It is also common in secondary prevention where treatment has to be cost-effective. The limit here is approximately €20.000 per life year saved. So why is there no limit in health care?

An important concept for determining such a limit is the quality-adjusted life year (QALY). One QALY means one year in perfect health; zero QALYs means death. It takes into consideration the actual time lived and the utility of the time lived, indicating that living a full year but being bound to bed is the same as living half a year in perfect health. The Dutch board for Health Care has proposed €80.000 per QALY a few years back, but this led to uproar by health care professionals and nothing has been done with the idea since. The former Dutch minister of health did not want to set a limit either.

However, the tide is changing. There is more support for drawing a line among medical specialists today. In addition, the total costs for health care are rising exponentially, partly due to the aging population, but also due to more expensive treatments. Measures have to be taken to ensure the costs do not exceed their limits. This is a controversial subject, though, similar to the issue of deductibles (‘own risk’). 

Maybe it is unethical to set a limit. After all, the amount of money is limited and a blank cheque might just cause financial troubles. Moreover, absence of a limit can lead to the introduction of ineffective or only partly effective treatments, as these are covered by insurance anyway. Furthermore,there is a limit to what people are willing to pay. Is it worth paying a premium of €2.000 per month to cover the medicine that saves three lives per year, even if it means living in a smaller house and eating only water and bread? Probably not.

There is a middle ground  on the subject, though. It could be decided to offer specific expensive treatments to certain groups only, for example patients with a high chance of survival or only young patients. This would decrease overall costs and palliative care may be more appropriate. Of course, the question then arises whether such a differentiation is ethical. Another possible solution is to not set a limit, but to make a joint decision between physician and patient. Instead of just immediately prescribing that expensive drug, a patient may prefer palliative treatment with a higher quality of life.

Additionally  there is the problem of people who have knowingly self-inflicted the condition: a smoker who gets lung cancer or an alcohol abuser who has liver cirrhosis. Should they be allowed to put enormous pressure on the health care system if there is an expensive treatment that makes all their symptoms go away? Or maybe a lower limit should be installed? Then the height of this limit is another topic for debate.

Yet it can be unethical to not set a limit, too. Do we want to be responsible for those poor babies with Pompe’s disease, dying, because we do not want to pay €300.000 per QALY, way more than the proposed €80.000? These are tough decisions to make. Moreover, there can be treatments that are already in rotation and cost more than a potential limit. What will happen to patients undergoing these treatments? Simply quitting reimbursing the treatment seems unethical too, indicating that a limit only counts for future treatments. This could mean that a treatment introduced on day 1 can be reimbursed for patients all their lives, but a more effective treatment introduced on day 2 will not.

The problem of overtreatment can also play a role. This means that a patient dies of other causes than the underlying disease, despite being treatment for this disease. It could be argued that a high amount per QALY is not worth it then. Or does this go for any treatment? And it could be that a treatment just does not work at all in a patient where it was expected to work. A waste of money, then? Besides, what about patients with multiple conditions that can be treated with expensive treatments, exceeding the set limit? If one condition can be treated within the limit and another cannot , there is not one clear answer on how to tackle this.

Suppose we were to set a limit, who should then determine its height? The insurance companies, who could set the limit low to save costs? The ministry of health, who could set the limit high and have the majority of taxes go to health care? The Dutch Second Chamber, whose members are not experts on the actual numbers? Every choice seems to have drawbacks.

Finally, what should the amount actually be? It can be arbitrarily set, in fact. With any given amount some people will be able to receive treatment, and some will not. Ultimately it is a matter of the number of people who will die which is acceptable to either the insurance companies or the government.

This article probably raised more questions than it has answered. Hopefully it got you thinking about cost-effectiveness in health care, and the implications that macro-decisions have on the lives of individuals - literally.