Let’s Get Personal

As recent history shows, research advances are not cheap, and focusing on the individual can be very expensive and, indeed, can skew healthcare funding and detract from outcomes for the population as a whole. As is well documented, despite healthcare expenditures that, on a per capita basis, dwarf those of other Western countries, American life expectancy is lagging, and childbirth mortality is shockingly high. In the absence of a comprehensive vision for allocation of healthcare resources, focusing on the individual can be very, very expensive, as reflected in the relentless growth of healthcare expenditures that outstrip inflation.

What should be done for Joe the Plumber’s aching shoulder?

Except for vaccines, most new therapies or interventions to improve health outcomes increase, not decrease, costs. Often, it takes a bunch of smart pharmacoeconomists to develop models and juggle the math of quality-adjusted life years to demonstrate that certain treatments are worth the costs in a dollars-and-cents way. For new oncology drugs with price tags that are in the six-figure range, there is sometimes not even an effort to justify costs by standard metrics, likely because cost-effectiveness would be impossible to show.

As discussed ad nauseum by the experts, the healthcare industry (at least in the United States) is unlike any other industry, and the usual rules of the competitive marketplace do not pertain. Although the cost of countless consumer items has dropped, even plummeted—witness computers—the costs of medicines have gone in the opposite direction. Many reasons account for this phenomenon, including the enormous costs of research and development, regulations, and pressure from Wall Street to create blockbuster drugs. However, it could be exacerbated if emphasis on a personalized approach continues unabated.

Focusing on the individual leads to products to fill smaller and smaller niches as drugs are designed to target much more selective genetically and genomically distinct variants of a disease. Developing drugs for a market that looks fractal-like in its complexity takes big bucks, and, unless the market is constrained or regulated in a new way, costs will continue to skyrocket.

Alas, the rocket is running low on fuel. The world flounders in economic uncertainty as words like meltdown, crises, and depression fill the daily lexicon. With a budget deficit soaring into the trillions as the government takes over banks and tries to rescue automakers, the pressure on budgets will be fierce. Money is scarce, and I cannot imagine that funding for federal programs for healthcare will rise. I suspect that it will contract. Furthermore, with unemployment increasing and the automakers try to jettison the insurance obligations of their retirees, the well could go dry.

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.

What should I do to provide the most cost-effective care to soothe the pain in Joe’s throbbing shoulder? Do I think only about Joe? What is the place of systems-based practice? Where do I factor in the reluctance of some to spread the money around as required by any insurance system, whether supported by taxes or healthcare premiums?

In my mind, I can see a few options that I can frame as a multiple-choice question. What should be done for Joe the Plumber’s aching shoulder?

1. Prescribe a nonsteroidal anti-inflammatory drug and teach Joe some exercises;
2. Inject the subacromial space with methylprednisolone (DepoMedrol);
3. Perform an ultrasound, and then do the injection;
4. Send Joe for the MRI that he requests; or
5. None of the above.

Let’s get personal. I know what I would do for Joe. What would you do?

Dr. Pisetsky is physician editor of The Rheumatologist and professor of medicine and immunology at Duke University Medical Center in Durham, N.C.