Pharmacy & Therapeutics - January 2009 - (Page 24) OPINION Economic Instability and Its Impact on Decision Making in Health Care F. Randy Vogenberg, RPh, PhD, and Stephen Cutts, PharmD Candidate INTRODUCTION It’s no secret that the current economic crisis is having a major effect on the myriad financial decisions that individuals and families are facing. This is especially true in terms of health care usage.1 The situation has posed tremendous difficulties for working and retired people, forcing many to forgo some basic needs, such as food and housing. Those who are fortunate to be financially stable enough to continue to afford basic necessities are now being forced to choose between health care and other basic needs, and people who were once financially secure are feeling the strain from increasing health care costs and decreasing economic security.2 Cost has prompted a perceptible shift in our traditional societal view of the priceless nature of life toward a view that now requires us to attach a value to life, often in the form of a price tag. This dilemma is particularly trouF. Randy blesome for patients with chronic illVogenberg, nesses, whose medical costs account for RPh, PhD a substantial portion of annual health care spending in the U.S.3 THE EXAMPLE OF CANCER Newer treatments have increased the life expectancy of cancer patients, in many cases changing the illness from an acute condition to a chronic disease that must be managed with maintenance therapy.4 This results in an older age demographic that is living with various types of cancer, often into retirement age (i.e., beyond age 65). With the economic recession, consumers’ assets and savings have plummeted; some of the hardest-hit individuals are retirees and workers who had hoped to retire in the near future. Chemotherapy treatment, especially with newer biologic agents, is expensive and poses a significant, ongoing financial burden to patients even when the economy is doing well. Partly as a result of the high cost of newer monotherapies or combination treatments and the increases in commercial and Medicare insurance cost sharing, Dr. Vogenberg is Principal at the Institute for Integrated Healthcare in Sharon, Massachusetts, and Adjunct Instructor at the University of Rhode Island’s College of Pharmacy in Kingston, Rhode Island, and Senior Fellow in Health Policy at Thomas Jefferson University–Jefferson Medical College, in Philadelphia, Pennsylvania. He is also an editorial board member of P&T. Mr. Cutts is a pharmacy student at the University of Rhode Island’s College of Pharmacy in Providence. patients’ health care costs have grown year after year.5 The use of expensive biologic therapies, which are now recommended because they offer slight improvements in effectiveness (as well as a substantial profit margin for oncologists) has also contributed to the financial strain borne by patients.4 Cost is now considered a “side effect” that cannot be ignored when a patient begins or continues cancer treatment. As illustrated by a recent report, many cancer patients are declining treatment deemed necessary by their oncologists, choosing to preserve their finances instead of their health.6,7 This “resignation to fate” may be seen in patients at the end of life who are undergoing palliative care as well as those who are receiving standard maintenance therapy to induce or prolong remission. This new trend in health care economics is one that requires rethinking of therapeutic decision making by all health care stakeholders, Stephen Cutts, including physicians, insurers, employPharmD Candidate ers, and the patients themselves. In fact, new guidelines that direct physicians on how to approach patients about cost, in their discussions relating to therapy, were expected to be released by the time this issue of P&T went to press.8 This crisis, involving medical expenses and their impact on therapy as well as how decisions are made vis-à-vis discontinuing or refusing treatment, challenges our currently accepted societal notion that life should be prolonged at all costs. Instead, patients are now considering the effect of their decisions not only on themselves but also on the present and future financial well-being of their families. IMPACT ACROSS THE HEALTH CARE SPECTRUM This shift in thinking is not isolated to oncology; it is observable across the entire spectrum of health care. Spending on prescription drugs as a whole decreased for the first time in a decade during the first and second quarters of 2008, and elective procedures, such as knee replacements, have also declined.9 Patients are reporting fewer visits to their physicians; also, they are not taking medications as prescribed, so that they can extend their supply of medications and reduce the frequency of pharmacy visits. Both of these practices enable them to avoid copayments. Patients are now beginning to look at the value of life from a new vantage point. As a society, we have been conditioned to believe that everyone has the right to prolong life if a treatment is available and that this right should be exercised regardless of the cost or the length to which life may be extended. Disclosure: The authors have no financial or commercial relationships to report in regard to this article. Accepted for publication December 2, 2008. 24 P&T® • January 2009 • Vol. 34 No. 1
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