Prostate profits

A recent decision by Medicare to cover a new vaccine by Dendreon (Provenge) for advanced prostate cancer (development story here) was anticipated by lots of speculation on the reimbursement price.  I wanted to reflect on this as kind of a general case in medical 'science.'

Certainly, advanced prostate cancer is no picnic. But it is likely vastly over-treated, especially in older (> 70 yo) men.  Nevertheless, goals to extend life through more treatment continue to drive research and folks, like Dendreon, occasionally can persevere and bring new technologies to market that demonstrate some advantages.  In the case of Dendreon, the advantages are an extended mean life expectancy for roughly 21 months to 25 months.  Four months.  Two notions I'd like to ponder here.  The first is simple, just about the mean or average, where it is just that, an average and some folks in both groups had higher and lower life expectancies.  One quirk of these kinds of statistics is that the 'average' cannot be applied to individual cases.  Huh?  A clinician could recommend this vaccine to patients saying something like, "In a published study, folks in the group taking the active drug survived, on average, 4 months longer than those who did not."  If the patient hears, "If I take this drug, I will survive an extra four months," they are wrong.  Some of the patients taking the drug may have survived 4 months longer, maybe not.  Certainly, some patients survived more that an extra four months, maybe a lot more.  And then some died before they reached four months.  Oh, and some died, even though they were taking the drug, sooner than the average person NOT taking the drug.  So any individual patient could have any of these individual outcomes.  That is now a bitch to figure out.  Sorry.

Okay.  Gamble with the drug.  Just have to have someone pay the freight.   $93,000.   You heard me.  $93 K, for 3 treatments in a month.  Of course, as a monopoly, what's a payer to do?  Either deny coverage (generate outrage) or suck it up.  The beauty of this example is myriad.  Since Medicare only pays 80%, there is an $18,600 co-pay.  Some folks might have that, or part of it, covered by supplemental insurance, but it still will be a  chunk of change. Think of the bank of dunners at the call center, haranguing elderly cancer patients for the co-pay.  Better yet, the mark-up that will be charged by clinicians, but embedded within the $93 K.  that works because Dendreon will give discounts to big purchasers, who then can mark it back to the $93 K and pocket the difference.  Of course, that would increase the likelihood of prescribing, one would think....

Lastly, this fits into the idea of a 'prefect' medical advance.  The therapy isn't curative, so the patient stays in the pool of revenue generating cases and the therapy does not require a reduction in any other intervention. The cost simply gets added to all the existing costs.  And if the average patient does get the 4 months, that is 4 more months of production, in terms of opportunities to render care.  Every one wins.  Except for the payers.  Oh, and the poor slob who would have survived much longer if no one would have diagnosed him with prostate cancer in the first place.