Solvadi, the new Hepatitis C drug that costs $80,000 or more for a three month course of treatment, is producing an interesting and instructive set of case studies of implicit and explicit decision rules as to who gets the drug. There is a limited supply of Solvadi and payers are extraordinarily reluctant to pay $80,000 to everyone who has Hepatitis C as that would destroy their cash flow for the year. This statement applies to for-profit insurers, it applies to non-profit insurers, and it applies to governmental programs such as Medicaid and CHIP. So the question that is raised, either explcity or implicitly, is who gets the drug? There are several different methods that could determine this result.
The first one is a free for all for a limited supply of doses. Anyone can get the drug if they are within the first X number of people on the list as that is the number of doses the payer can afford to buy this year. I have not seen any explicit cases of list based distribution as this type of system is rife with lawsuit potential and absolutely horrendous news stories. It is also inefficient as there are several stages of the disease, and some people who would be treated on the list method would be at a stage where their health and quality of life had not been compromised while people with few remaining good options would be left waiting. Part of the control functionality could be placing Solvadi on the highest tier of drugs so that there would be a $5,000 or $6,250 (max allowable) out of pocket co-pay. It would be a scheme targeted for the rich, well insured, and/or connected.
The second method is a prioritization method based on clinical indicators. Anyone with Hep-C could get the drug and see improvement, but the drug would be reserved for those where Hep-C has already caused significant liver damage. At this point, the goal is damage limitation via a late arriving cure instead of damage prevention. From a public health point of view, this is fixing the water damage in the ceiling instead of being able to take care of the roof during the sunny season of reasonalbe health. The upside is that we know the drug is being effectively targeted. The major downside is that we also know that people who are currently in okay shape will go to significantly worse shape in the future. It is a temporary solution until there are either competitors on the market, public shaming brings down the price, or fear of regulatory action brings down the price.
The third method could be the most controversial. It is a modification of the second method in that it seeks to identify high priority needs. The diffrence is that it is a hybrid of personal health and public health. The goal of the third method of distributing very limited and expensive drugs would be to attempt to distribute to people who are both sick and highly likely to infect future individuals. The goal is to minimize future infections and thus future demands for Solvadi.
How would this be done?
We know that the primary infection transmission profile of Hepatitis C is from blood to blood contact. It takes effort and personal contact to spread Hep-C.
In the United States, that typically means drugs being injected by shared, uncleaned needles. There are other modes including household blood to blood exchange such as sharing an unsterilized razor blade, but the most common is drug usage. The goal would be to identify people who are in high risk behavioral pools that include significant number of non-infected individuals and then treat them aggressively. The rule would favor individuals who are the only member of a high risk behavioral risk pool who is currently infected as they would be the most likely source of multiple future infections.
However, if an individual is a member of a high risk behavioral pool where a very large proportion of the membership is also infected, treatment in the public health infection transmission minimiziation mode would not be effective for two reasons. First, there is a reasonable risk of reinfection. Secondly, any infections that are averted by treating a high risk for tranmission individual would most likely be “replaced” by transmitted infections from other sick members of the pool to other healthy members of the pool. People who are in a high risk pool that is entirely infected would not be candidates for infection transmission chain breaking doses. For instance, a husband and wife who are both HEP-C positive from a bad tatoo years ago but are otherwise in pretty decent health AND not engaged in any other high risk behaviors have minimal infection transmission risk. Under this schema, they are not good candidates for Solvadi as the benefits would only acrue to them and not to any potential future infections averted. If their health went downhill, that is another story.
This schema is based on the studies of how HIV is transmitted in Africa. The studies showed that there were a few key players who could block most infection routes. Long distance truck drivers who frequently saw prostitutes in multiple cities acted as conductors of the disease between otherwise disconnected clusters. Prostitutes acted as local mixers where there were numerous infection opportunities. If there are a large number of infection opportunities, then the laws of disease transmission probability come into play. The research showed that targetted condom distribution, education and treatment to long haul truck drivers and prostitutes would often be the most efficient way to reduce future infections using solely medical resources. (Getting women out of prostitution through improved economic stability would also be a good approach but that is another story for another day.) The insight was that most diseases are social diseases so disrupting a few key nodes of the social network graph of transmission would produce massive results for relatively low investment.
The downside to the hybrid personal health/public health transmission attack methodology is two fold. The first is political. Expensive, high value, high efficiency drugs would be given to THOSE PEOPLE instead of Good Middle and Upper Middle Class People. THEY DON’T DESERVE IT. Specifically a good proportion of these drugs would be held for drug users. That is a great way to get a crab-bucket politics shit-storm. Secondly, it would require a national coordinating entity with significant participation of most major payers and providers. Some method would be needed to determine who would be a good candidate for both personal and public health purposes. That can’t be done well if some insurers will buy Solvadi for anyone who can meet the $6,250 cost-sharing requirement for the Tier 99 drug, and others engage in honest public health evaluation. As it is, this schema would most likely initially be paid for disproportionally by Medicaid, so new resources would be needed. Again, this is partially a technical problem (coordination) and partially a political problem (death panels vs. technocratic public health measures that don’t prioritize the privileged).
My guess is that most payers for at least the two years will adapt the second method; Solvadi prioritization based on clinical indicators. This means there will be more future infections but from every payer’s point of view, that future infection is most likely someone else’s problem.
PurpleGirl
I’ve known two people who died from Hep-C. One was a co-worker; he was also diagnosed with HIV. But the Hep-C got him first. The second was a friend’s brother who probably got the Hep-C from blood transfusion in Vietnam after he was wounded. This was before they ID’d Hep-C. It took a number of years but the Vietnam war got him in the end.
Mojo
Excellent post. Thanks.
NotMax
Hepatitis.
polyorchnid octopunch
I did notice that in option two there was a possibility left unmentioned; having the price come down with actual regulation. You know, have the state come in, say “here’s our eminent domain price on your patent, now fuck off and enjoy your money while we go about actually making sick people better.”
Should be a fairly low one in this circumstance, given the public health angle on it… put the fear of god into other drug makers so they keep their prices more reasonable.
Keith G
I would suppose that there will be a screening process to identify those who have a history of noncompliance with the previous HCV therapy as well as other conditions making adherence to a 24 week regime dicey.
In my work at a hospice, many of our residences are facing mortality due to Hep C and not their underlying HIV infection. In the majority of those cases a history of noncompliance is in their medical records.
These days, when a new resident is transferred to our care chances are they have just been through a period of noncompliance. Troubled as it might be, our healthcare establishment is getting really good at keeping HIV patients alive – unless they drift in and out of their medication regimes.
Richard Mayhew
@polyorchnid octopunch:
Yep, that is part of the equation — if there is a fear of regulatory action to bring the drug pricing down to say $20,000/course of therapy, then quite a few considerations change…. I don’t think the probability of that happening is higher than my 2 year being able to potty train himself this week without accidents though.
FlyingToaster
@polyorchnid octopunch:
Not in these United States. The Big Pharma lobby pretty much owns our legislators (see Pfizer, Eli Lilly, and GlaxoSmithKline).
jayackroyd
Channeling Dean Baker, I have to ask why the treatment costs 80,000 dollars? Does it involve harvesting a special gold isotope or something? Or is this patent rent?
http://www.cepr.net/index.php/publications/books/the-end-of-loser-liberalism
Dean’s book. Free!
Lee Rudolph
If (2) is what ends up being done, it presumably would also defer, or eliminate, some liver transplants and their associated expense.
Keith P
I’m on dialysis, paid for by Medicare Part B ($100/month). While I’m sure it gets negotiated down quite a bit, but along with injections, my *monthly* bill is about $60,000 (I got one in the mail from my last clinic on accident when my insurance changed). This crap is just insane; it’s like they hope to kill you with sticker shock before you realize you don’t have to cough up list price medical care.
Richard Mayhew
@jayackroyd: Good chunk is IP rent. The most straightfaced answer with minimal giggling is that Solvadi is priced at a point that is slightly below the current bundled price point of the next best alternative so it is a “good deal” but realistically, it is massive intellectual property rent.
Richard Mayhew
@Lee Rudolph: Mainly it would change who gets the liver transplants as there is a massive waiting list for livers and nowhere near enough livers. So instead of a Hep-C patient getting a new liver, another person with a different reason for liver problems would get the new liver. From a system POV, not much of a savings, although most likely a significant improvement in net quality and quantity of life.
Keith G
Here is one application/screening document for the use of Solvadi
Richard Mayhew
@Keith G: So Molina is going route #2 — clinical indicators for prioritization — got to be sick and got to be compliant
bbleh
There is another factor that needs to be taken into account. There are MANY new HCV drugs in the pipeline, ALL of them better than the standard of care, and most of which will provide an effective cure. Some of them will be on the market within a few years, and more not long after that. This will have two effects: (1) the prevailing prices will plunge, and (2) the huge “reservoir” of infective HCV patients will begin to be drawn down rapidly, reducing further infection rates dramatically and, in the middle term, effectively wiping out the disease in industrialized nations except for a small population of mostly IV drug users. (Industrializing and non-industrial nations will take longer, but ultimately they will follow the same path.)
The implications for treatment are that expensive (for now) treatment such as Solvadi should be used first, and perhaps only, for those patients who otherwise would need similarly expensive treatment, e.g., transplants. Patients who are infected but not “full-blown” or with substantial liver damage can wait until the next “wave” of drugs hit and prices drop.
jeffreyw
@jayackroyd: Moar Dean Baker on Solvadi.
oops, need moar link: http://www.cepr.net/index.php/blogs/beat-the-press/the-cost-of-sovaldi-would-not-pose-problems-if-elites-in-the-united-states-believed-in-free-trade
CONGRATULATIONS!
@Richard Mayhew: Really long past time for the government to step in and put an end to this. We pay FAR more for drugs than anyone else in the world – in essence subsidizing pharma R&D AND profits for the entire rest of the planet.
Richard Mayhew
@CONGRATULATIONS!: yep — if I was US healthcare dictator for a day, that would be one of the big things that I would do — declare for US government programs (CHIP, MA, Medicare, VA etc), that the US government would take as a matter of course, the best deal for a drug offered to a major OECD country (ie, the deals that Germany, Britain, Japan, Canada gets). The US gov’t would not negoatiate, but the price of a patent would be a mirror of the “best terms offered and accepted” agreement — that would drive massive price convergence between the US and the rest of the rich industrialized world. I exclude global “best price offered” as I want to exclude what is effectively charity doses going to Cameroom from consideration.
El Caganer
@jeffreyw: I just finished reading Baker’s piece. We can take Hep C patients, fly them first-class to Egypt or India, treat them with Solvadi, bring them back on a nice relaxing cruise, pay their rent for a couple of years…..and they’d still have a pocket full of folding money left over from that fucking $80,000.
MomSense
I have one prescription that I thankfully only need to take every now and then. It is over $700 for a thimble sized container. I think the problem in my case is how few people have this blood disorder.
ETA: There are some types of prescription eye drops that are outrageously expensive. I was pretty shocked when I went with my Mom to fill her prescription. Maybe it is putting the medicine in the thimble sized containers that makes the price go up??
? Martin
I would think that, on the assumption that they can ramp production of the drug faster than cases are being diagnosed, that doing the same mechanism as the transplant lists would be the most prudent. It would deliver the drug to people that are facing a life/death inflection point. It already factors for people whose lifestyle aren’t compatible with the treatment or who are too far gone for the treatment to help. And assuming that production is increasing, it would steadily bleed that list down to where it could be more widely distributed and presumably be more affordable.
Yes, there’s the THOSE PEOPLE problem, but that’s really only a problem if you are devising a new system. People have already come to terms (politically) with that problem the existing system so it shouldn’t be nearly as controversial.
Hob
@bbleh: I really, really hope that that’s where things are going; the only problem with trying to make policy on that basis is that the time frame isn’t necessarily so predictable. I had a hep-C-focused nursing job for a couple of years in the previous decade, which at that time meant interferon+ribavirin— a better regimen than they would’ve had 10 years before that, but still, pretty grueling and only sometimes effective— and we were very aware that there was all kinds of promising stuff in the pipeline that would probably make our current tools look medieval, but our guesses about how close that stuff was to availability kept being wrong, so we couldn’t really de-prioritize someone’s care on that basis.
Bobby Thomson
From a cheapest cost avoider standpoint, I completely endorse this “crab bucket view.” It’s a scarce resource, and if one approach to its use helps to prevent a disease among populations that can prevent contracting the disease by avoiding high-risk, illegal conduct that contributes nothing to society, then that’s not the most socially optimal use of the resource. In other words, “those people” can avoid contracting the disease by maybe not shooting smack instead, leaving the drug available for those who contract the disease through less destructive means.
Hob
@bbleh: Also I’m not sure that “patients who otherwise would need similarly expensive treatment, e.g., transplants” are necessarily good candidates for Solvadi. From what I’ve read so far, it is appropriate in the case of hepatocellular carcinoma, but in non-cancerous end-stage liver disease not so much.
Richard Mayhew
@Bobby Thomson: so to feel morally superior, you want more people to die
Good to know.
jayackroyd
@jeffreyw: Thanks very much for the link. I hadn’t seen it.
jayackroyd
@Bobby Thomson: Just so you know, the drug is not a scarce resource. The pricing is the result of a policy decision, not some natural phenomenon.
We hope (and I’m sure I include Richard when I see “we”) that this kind of publicity will help change policies wrt drug availability and, generally, IP rents.
Because the public policies are insane.
Bobby Thomson
@Richard Mayhew: Moral superiority’s got nothing to do with it. Use of heroin post-addiction is no longer 100% a voluntary choice, and assuming there is enough medicine to go around, should be treated as a public health problem. But if there are only so many doses of the Hep C treatment available – and your post says there are, though others suggest that isn’t the case and the scarcity is artificial – I have absolutely no problem with not giving drug addicts a preference over others for the doses. There’s a big difference between “Just let them all die” (in which you wouldn’t give addicts the Hep C treatment ever, even if their Hep C had progressed), which I don’t support, and “Make drug addiction a golden ticket for Solvadi.”
Someguy
Forcing a cramdown on the greedy pigs at the pharmaceutical companies would make it affordable.
Richard Mayhew
@Bobby Thomson: There is a shortage of funds to pay for all doses of Solvadi — there is no binding constraint on the physical production of the drug.
Richard Mayhew
@Bobby Thomson: As long as the price of Solvadi in the United States is more than the median income in this country, there will be a limit to the number of doses bought. The question then becomes how do those courses of treatment get distributed. We can distribute by price, by lottery, by luck, by sign-up sheet, by clinical indicator, by clinical indicator and public health concerns. There are numerous ways to figure out how a scarce (naturally or artifically) resource should be distributed. Each choice has its own set of trade-offs. The technocratic approach should be to outline what the trade-offs are within the schema and highlight what the function of the schema is at least trying to satifice if not optimize on.
The trade-off for a public health focus that is attempting to minimize future infections is that there will be far fewer future infections under this schema than under most other schemes as people who are prone to be central nodes in infection networks will be removed from those infection networks and this will lead to fewer infections, less suffering and over the long run far lower costs as not as many people will need the drug. It is analogous to targeted herd immunity. The downside is that the recipients of the scarce resource are more marginal, more dispossed and far less telegenic on average than recipients in other schemas. Recipients would include addicts who if left untreated or less effectively treated will infect 15 people who as of today are clean.
Your argument is a quasi-moral hazard argument that goes something like this — “Gee, let’s start shooting heroin with dirty needs, expose myself to Hep-C and a whole lot of other nasty diseases just so I can get to the front of the line for a single drug for a single one of those diseases….” Thankfully having never been an addict of anything stronger than coffee and tobacco, I can’t speak from too much experience, but from what I’ve read and been told, addiciton ain’t a ton of fun to begin with before having to dealing with Hep-C which is also a blast….
The moral/political side of the policy choice equation is to take the technocratic arguments as to what is or highly likely to be and apply value weights. What do you value? What should society value? That is not a technocratic argument, it is a moral argument. For me, my moral sense places high weight on minimizing suffering. For you, it seems you value other things significantly more highly than I do, and underweight some of my value weights.
? Martin
@Someguy: Well, we have a moral hazard problem here. The generics are still based on the research done by Gilead. That research needs a funding source if not from revenues from drug sales.
Yes, we could mandate that prices come down in line with manufacturing costs and then offload the R&D expenses to some other funding source, but what would that be? Should we put that as part of the nations grant funding process? We could, but we also know that the GOP loves to cut that and it keeps the burden of funding the drug in the US (which is fine in this case as Gilead is a US company, but most of these guys aren’t). That could be tied to US jobs – we’ll pay for drug R&D proportional to the number of jobs you make in the US.
Ultimately though we have the problem backward. Drug companies chase what will pay off, but they aren’t the ones paying the opportunity costs here – the rest of the healthcare system is. What was the cost of treating everyone with Hep C prior to the drug introduction? That’s where the funding incentive lives – finding a way to treat/eliminate the disease by shifting the long term costs of treatment into near-term costs of R&D. And then when the drug is available, you give it out, because you don’t need profits – you just saved yourself billions in long-term care.
So, what PPACA should do in its next expansion is put a mandate that non-elective drugs (that’s a battle in itself) can be sold at no more than x% above their marginal unit cost. In return, we set up an IPAB-like board that sets drug R&D priorities and funding levels, focusing on areas that will provide the best return on long-term health care costs. That might put antibiotics ahead of anti-cancer, but so be it. That money then comes out of Medicare, Medicaid and as a tax on health insurers proportionate to their market size and goes into a competitive grant pool. We can put a ceiling on that tax to make sure that the board doesn’t inadvertently bankrupt everyone.
We spend nearly $4T on healthcare in this country. Half of that is insured in one way or another. About $75B annually is spent on new drug research (globally), or about 2% of our annual spending. I think we can swing that. Bunch of sticky details in there but it at least turns the problem around where the incentives belong.
Earl
@Richard Mayhew:
Your statement is bs: people are going to die either way, unless and until we figure out a way to get everyone with hep-c this drug. Don’t pretend @Bobby Thompson is choosing between people dying or not dying. But good job knocking down that strawman.
Unless we either (1) give everyone who may need it $80k a pop meds (not going to happen), or (2) cram down the manufacturer (not going to happen soon), we are picking who lives and who dies. Or, at bare minimum, who continues to be damaged by the disease. Since I don’t see a near-term way out of rationing, I have a hard time eg not prioritizing people who didn’t get this through needle sharing over those who did.
As we (hopefully) move towards universal healthcare, the downside is those costs are going to be viewed as coming out of your and my pockets. Nobody should be surprised when taxpayers get grumpy about others’ high risk behavior.
Earl
ps — and to make my politics clear, I’d rather we had universal healthcare, 1/3 or less the military spending, and an end to subsidizing drug R&D for the eu. But we aren’t there, and aren’t going to be there any time soon. So right now, despite lamentations, our job is to debate whom we think should die.
Richard Mayhew
@Earl: yeah, and minimizing future infections minimizes future deaths.
bbleh
@Hob:
Yes, I meant HCV patients requiring transplant, or more generally, patients for whom similarly expensive HCV treatment in the near term is the only alternative.
The next “waves” are indeed much closer — several submissions are expected within the next year — and interferon-free treatments are well along in clinical trials. And those treatments do indeed provide effective cures, although some are genotype-specific. (Solvadi is not.)
Gilead is making hay while the sun shines. But the clouds are coming.
jl
Unless some ethical drug maven can explain how I am mistaken, Sovadi is not scarce. It is under patent, so the company can create scarcity and increase profit using monopoly pricing.. The economic cost of production is far lower. It costs around a a thousand dollars to make in India.
If it were not for the fear of the reference pricing effects by other large purchasers, I suspect the company would be happy to provide the drug to anyone at price down to actual production cost, since they would make more money that way if they could enforce to price discrimination, which the growth of reference pricing domestically and internationally threatens if the drug is sold at a lower price on the market. Maybe to some extent the price cuts needed to sell more are called compassionate care exemptions for financial need in order to keep those sales out of other large buyers’ calculations on what should be the proper reference price.
I don’t know whether US legalities would permit it, but imposing a controlled ‘haircut’ on company profits from the drug patent monopoly through compulsory licensing to other manufacturers is another way to bring the price down quickly. A lower price would solve a lot of dilemmas presented here. I don’t know much about when compulsory licensing can be legally enforced in the U.S. when a monopoly patent causes to much restraint of trade in the short run, and too much economic rental income off the IP.
WereBear
Why ration a high-priced drug when you could sell more for less money, and wind up the same?
Remember on this essay question, that a lot of the high-priced research is paid for by taxpayers.
Villago Delenda Est
@Earl:
CEOs and MBAs, investment bankers, hedge fund managers. Really quite simple.
OT, since there’s no open thread: Noisemax, strikes again!
Cheney: Obama ‘Absolutely Gutting’ US Military
Right. This from the guy who, along with his nominal superior, gutted out many of the best and brightest in the US military with their great Mesopotamian adventure.
Someone find those horcruxes, stat. The Dark Lord needs to be destroyed.
MikeB
Spelling Police here, I’m looking at a bottle of SOVALDI as I write this, so take note of this valuable piece of knowledge I’m sharing with you all :)
My wife has battled Hep C for many years, had a liver transplant in 2006. Hep C came
back (it always does) and they tried interferon/ribavarin which almost killed her.
Her hepatologist let her know last year that these new drugs were coming out.
There is a two pill treatment available, Sovaldi plus Olysio, for people who can’t tolerate
combination therapy with Sovaldi and interferon/ribavarin. The additional pill bumps the
price for 12 weeks of treatment up to $150,000.00!!! At present you have to be
“interferon ineligible” as determined by and documented by your physician to qualify
for the two pill treatment. You also have to have cirrhosis, which she has in her
new liver thanks to the return of the virus. So I guess she fits into category two.
Our insurance initially turned us down, but after appealing that decision and providing
copious documentation and letters from prominent physicians, they probably determined that she might be needing another transplant in the not too distant future
and approved her. She’s halfway through the course of treatment and is presently
virus free (woo hoo) and we are hoping that at the end of it she will be cured.
These truly are “miracle” drugs compared to the old regimen. and yes, the drug companies are trying to make as much money as they can before the competition comes along, which will be soon (next year, I’m told.)
By the way Richard, many thanks for your informative articles on the intricacies of
health insurance policy, I always read them and recommend them to others.
The Sailor
I think 2 premises are incorrect:
it doesn’t cost $80k, that’s what they charge for it.
Hep C can be acquired thru sex & toothbrushes. Less likely than blood xfusions before 1992, which in case it should have been covered by lawsuits.
You should have just asked how many Ebola patients we should let live. 1st world care, it’s 20 to 40% mortality. 3rd world, it’s 60 to 80%.
Still, one out of 4 will die, why bother spending any money on them, ammirite?
Health care spending isn’t the problem, military spending is.
[ETA]
I’m not in a good state of mind today, I’m getting sick of not being able to help people due to ‘the budget’.
? Martin
California’s rate changes are coming in.
4.2% increase is better than we’ve seen in the past, but still higher than inflation. It’s progress, though.
Villago Delenda Est
@? Martin:
Flying in “office supplies” from the Andes isn’t cheap, you know.
Tissue Thin Pseudonym (JMN)
@Richard Mayhew:
Yes, it does, but you are advocating public subsidization of risky behavior. There is an ugly moral tradeoff here and your efforts to pretend that it isn’t a trade-off undercut the effectiveness of your arguments. If you cannot understand why it is morally compelling to prefer to treat people who did not engage in risky behavior then you will never be an effective advocate on this issue.
It’s not a question that has a simple answer, so stop pretending that it does.
MikeB
A few observations from a reluctant “expert” with 15 years experience, my wife and I have been married 22 years and I don’t have Hep C. Hepatologists will tell you that Hep C is rarely transmitted sexually. It is theoretically possible to pass the virus via toothbrush, but highly unlikely. I’ve been told by transplant people that low risk patients get the disease as often as high risk patients, and most patients don’t know how they got it. Doctors didn’t even know what it was before around 1989, they used to call it Hepatitis non A non B.
Also it’s useful to remember that Hep C is a slow moving disease, with damage to the liver often taking 10-20 years to manifest clinically. This makes it possible for insurance companies to deny treatment for less urgent cases while waiting for the price to come down.
A liver transplant surgeon we know is switching to kidneys, as he sees the handwriting on the wall for future liver transplants.
“Health care spending isn’t the problem, military spending is.”
Agree completely.
lefthanded compliment
Those inclined to blame intravenous drug users for their consequent health problems might want to educate themselves about the relationship between addiction and a history of childhood trauma. Here’s what Dr. Vincent Felitti, co-investigator for the ACE (Adverse Childhood Experiences) Study, had to say: “If you compare a male child with an ACE score of four with a male child with an ACE score of zero there is approximately a 12-fold increase in the likelihood, that is to say a 1,200% increase in the likelihood of that male child growing up to be an intravenous drug user. If you go out to an ACE score of six, it jumps to 46-fold or 4,600%.”
Kylroy
@Tissue Thin Pseudonym (JMN): If your goal is reducing the total number of future infections and deaths…yeah, actually, it does have a simple answer: medicate the people who are likelier to infect other people. The idea that there’s a moral hazard here is ridiculous – do you honestly think anybody’s thought process will be “I wasn’t going to do intravenous drugs, but I changed my mind when I heard it would put me to the head of the line for Hep C medication”. There is a nontrivial threat that *existing* Hep C patients may lie about their behavior to get favored treatment…but that’s going to be true of *any* criteria used to ration the medication.
If you are going to value different patients’ lives at different amounts, then it does become complicated.
jl
@MikeB: SOVALDI is a typo-rich environment.
Tissue Thin Pseudonym (JMN)
@Kylroy:
And if you think that ever can be the only goal of public policy, you’re deluded.
No, I don’t think that exact transaction has taken place in their mind. However, the transaction that did take place is, “I’m going to engage in this behavior even though it has substantial risks.” And if you cannot understand why many (most? maybe) people would rather provide treatment to those who did not engage in that risky behavior, you’re a dullard. And I suspect that there are plenty of situations in which you do recognize that trade-off; I suspect that telling those in the financial industry that you have no desire to subsidize the losses of their risky trades is one of them. It’s the same principle at work.
Risky behavior has risks. Treating the people who have engaged in those risks the same as those who have not is always going to be a hard slog and in most cases, it should be.
The problem isn’t that I’m valuing people’s lives at different amounts. It’s that they have valued their own lives at different amounts. Someone who engages in a behavior that carries major risks to their health values their own life less than an otherwise identical person who does not engage in it. They may not have made that calculus consciously, but they have made it.
And none of that is to say that the option Richard is pushing is the wrong one. It may well be the right way to go. But if you can’t understand how it is a moral trade-off, you will never be an effective public advocate and, in my mind, you are also morally deficient.
The Sailor
“you are advocating public subsidization of risky behavior”
Are you just slut shaming, or do you include everyone who has risky behavior?
e.g. All them car accidents, totally preventable.
Climb a tree, yup, we won’t pay for it.
Cancer!!! It’s your own fault.
Swimming, my god man, you took the risk of swimming?
Oh, you crossed against the light? And you think your insurance covers that?
I will repeat, trim the defense budget and this would not be a financial concern. Especially considering how many injuries are incurred just training for the defense budget.
Tissue Thin Pseudonym (JMN)
@The Sailor:
If someone engages in a risky behavior that has material consequences for the remedy involved, yes. In this case, you would be handing out a scarce resource* to someone who both contracted the disease through risky behavior and is also more likely to simply recontract Hep C by continuing that behavior instead of giving it to someone who didn’t engage in the behavior to begin with and for whom the drug is more likely to actually do long term good.
And, frankly, I don’t even understand why it’s so hard for people to understand that the person who contracted Hepatitis C because of taking known risks by choice ought to be lower on the priority list all other things being equal (which in this case they are not, given that there are other public health concerns and thus a more complicated question) than someone who got it without doing so. There are a lot of instances in which people around here scream ACTIONS NEED TO HAVE CONSEQUENCES; well, this is one of those cases. Once we free up the supply and have enough for everyone then I have zero problem with ensuring that everyone gets it. However, so long as you can give the drug to one and one only of Person A or Person B, then how they got it ought to be a criterion in the decision. Again, not the only one, but it should be included.
*For the purposes of dispensing the drug, it really doesn’t matter whether the scarcity of the drug is artificial or not. Steps to reduce the patent rent and increase the supply of the drug would be great but they are also tangential to the question of dispensing the drugs we have until such time as supply increases.
The Sailor
“If someone engages in a risky behavior that has material consequences for the remedy involved, yes.”
So, all that tree climbing and swimming, drove a car too fast, fucked people they shouldn’t have ( in hindsight), let them all die.
I bet you were a laugh with all your gay friends when they were dying of aids.
Tissue Thin Pseudonym (JMN)
@The Sailor:
IF the things that would keep them alive are sufficiently scarce that we are talking about what sort of system we have to use to allocate them, then yes, that’s a consideration. However, if you strip out the conditional, then you are lying about what I said.
polyorchnid octopunch
It sure seems like there’s nothing that’s not a morality play to Americans.
And you wonder why your health care system’s so fucked for so many of you.
Sad, really.
sempronia
@Tissue Thin Pseudonym (JMN):
The idea of limiting a scarce resource like Sovaldi (ok, it’s artificially scarce, different discussion) to people who “deserve” it was already addressed decades ago by the transplant community, i.e., the same people who are handing out the Sovaldi today. A conscious decision was made to avoid judging eligibility for an organ (a for-real scarce resource) based on previous behavior. Former drug users get transplanted all the time – and that includes alcohol as well as smack-shooters, lest you get too self-righteous out there. They just have to be dry/clean for six months to be listed. But if someone comes in with fulminant liver failure and is about to die, even if s/he is an ongoing alcohol or drug user, that person goes to the top of the list, because it’s the only shot at life and we believe in second chances.
We’re not supposed to choose who gets an organ based on our moral judgements. The allocation criteria are purely clinical measures of disease severity to avoid exactly this issue. Else some DFH transplant surgeon might have judged Dick Cheney unworthy of a heart.
So this is a solved issue. That’s how it’s supposed to work, in theory, even though sometimes places will turn a blind eye to some patients’ less than strict adherence to sobriety.
Birthmarker
I am going to assume that insurance companies have negotiated a better price with Gilead for the medication. I would guess the federal government hasn’t. (Didn’t Bush and Congress forbid govt negotitions for meds by law?)
It seems short sighted not to just knock the virus out, rather than continuing on with lifetime treatment…
Hob
@sempronia: Not to mention that the moral-hazard argument would only have a chance of making sense if it were a question of limiting one scarce resource, in a vacuum, which isn’t the case. If you don’t spend $X to treat an addict’s hepatitis C, that person does not just go away and quietly shuffle off through the door marked “Undeserving, Will Need Nothing Ever Again.” Instead, that person remains chronically ill for years, often unable to work, regardless of how well they’ve gotten their shit together in terms of the addiction. And at some point chronic becomes acute, and that person requires any number of medical interventions up to and including transplant. But at least we remained pure, by not helping eradicate the virus from someone who had engaged in risky behavior!
Having worked in public health and harm reduction, and having known many, many fine people who got themselves into and then out of bad situations and went on to bring good things to the world, I don’t want to spend one more minute arguing with assholes who think this way. They can’t possibly be unaware that it only takes one mistake to get infected, and that in many cases it’s just impossible to ever know how someone got infected, and that we all take other kinds of stupid risks all the time. They just don’t give a shit, because those people are not people to them, or because talking tough like that is fun.
Kylroy
@Tissue Thin Pseudonym (JMN):
So…you *are* valuing people’s lives at different amounts. You’re doing so based on their actions, you may have valid justification for stating their life is worse less than someone else’s, but don’t pretend you’re not doing it.
It is. Except it has never been tested on Wall Street – when we see huge swaths of the financial industry imprisoned for life, we can then see if it instills some sense of caution in the remaining people. But junkies have been meeting horrible ends for decades (hell, centuries), and it doesn’t seem to be discouraging people from taking up the habit.
Satisfying as you may find it to see junkies sicken and die, it does not in fact serve any useful purpose.
It’s absolutely a trade-off. The trade off is letting one person go untreated for the sake of treating another person today,preventing a dozen infections in a decade, and possibly moving the disease to the margins in a century. A moral trade-off? For people more concerned with treating the “right” people than reducing disease, yes. Public health should advocate the greatest good of the greatest number (being public and all), and I don’t think that approach makes it “morally deficient”.
ecks
@Richard Mayhew: And if you indexed the price the US would pay to the best deal offered to other industrialized nations, the price everyone else pays would soar, because they’re all smaller markets than the US. The drug companies would set the price they wanted the US to pay, and take hits elsewhere as needed.