A Possible Solution?
One approach to lowering healthcare costs would be to make medical care less personal and to have patients and physicians accept outcomes, which, while good, may not be optimized for every individual. Consider the treatment of rheumatoid arthritis (RA), where individual responses to tumor necrosis factor (TNF) blockers may differ among the currently available agents. Until we know a lot more about the determinants of responses, one approach would be try each of the TNF blockers until an effective one is found, or the decision is made to go on to something else.
Such an approach can be justified, but it is expensive because it involves a lot of trial and error. By its inefficiency, this approach can keep drug prices high, require larger inventories, and limit competitive bidding. If, by some chance, I ran a pharmacy service for a healthcare organization, I would like to purchase drugs in bulk and bargain for discounts for the size of the purchase. Under the circumstances, I might stock only two of the five TNF blockers, choosing the ones whose manufacturers give the best price. This is Costco care, not that of Neiman Marcus.
The Costco care strategy would likely work for 95% of RA patients and would save money. Some patients, however, would no doubt have less than fully satisfactory results because they would lack access to the drug that worked best for them. The personal loss would be counterbalanced by the public gain to the extent that it is worthwhile to decrease healthcare expenditures overall (especially in a weak economy) or allow money saved on RA to fund other priorities in the system. In a time of fiscal constraints, something has to give, and I would rather that patients and providers make the choices rather than the pressures of the marketplace or arbitrary decisions of the bean counters.
Making Personalized Medicine Personal
Imagine now that Joe the Plumber has decided to move from cold and cloudy Ohio to the sunny, verdant, and congenial state of North Carolina. Joe has heard that homes are still going up in Holly Springs and Fuquay Varina and that plumbers are needed to install showers (times are tough here, too—no more Jacuzzis). Joe has also seen the light in sports and will forsake the Buckeyes for the Blue Devils or Wolfpack.
In his newfound home in the South, Joe works like a demon and, in a hurry one day, he yanks hard on his wrench and suddenly his shoulder erupts with pain. Joe comes to see me, and my exam shows limited range of motion and signs of impingement. Joe says that he wants an MRI because one of his buddies on the job with similar complaint had one and got better.
