Medicare Prescription Drug Benefit Realities

David K. Cundiff

In This Article

Terminal Illness Treatment Realities

The FDA recently approved gefitinib (Iressa) in patients who had failed first-line chemotherapy consisting of cisplatin (Platinol), which is not itself FDA approved for non-small-cell lung cancer,[8] and docetaxel (Taxotere). The FDA approval of gefitinib is based on one uncontrolled trial showing 10% of 216 patients had 50% or more shrinkage of tumors lasting for more than 1 month.[9] Results from 2 large, controlled, randomized trials in initial treatment of non-small-cell lung cancer showed no benefit from adding gefitinib to standard, platinum-based chemotherapy.[10] Iressa costs $1700 a month[11] and has a potential market of 125,000 non-small-cell lung cancer patients (mostly Medicare recipients) per year.[12]

Most deaths of Medicare recipients occur after an advanced or terminal phase in which symptomatic care alone without aggressive interventions (ie, hospice) should be employed. However, aggressive treatments attempting to prolong life in terminally ill people typically continue far too long. Reflecting this overaggressive end-of-life treatment, the Health Care Finance Administration reported that about 25% of Medicare funds are spent in the last 6 months of life (about $68 billion in 2003 or $42,000 per dying patient).[13] Actually, the last 6 months of a Medicare recipient's life consumes about $80,000 for medical services, since Medicare pays only 53% of the bill.[14] Dying cancer patients cost twice the average amount or about $160,000.[13]

A comparison of the utilization of Medicare services in different regions of the United States showed that high spending regions provided 60% more services, including end-of-life care, than low spending regions. Quality of care and access to medical services in the high spending areas were equal or worse than in the lower spending areas.[15] Assuming that the lowest spending regions have no overutilization of services, this translates into a best-case scenario of $70 billion of Medicare fee-for-service funds wasted in 2003. Given current Centers for Medicare and Medicaid Services (CMS) cost projections,[2,14] eliminating this overutilization of Medicare services would save patients untold misery and more than $400 billion in out-of-pocket expenses from 2006-2015. Medicare, Medicaid, and other insurers would save about $1.2 trillion, $300 billion, and $400 billion, respectively.

Compared with these dizzying cost estimates for Medicare waste, national expenditures devoted to the Medicare Hospice Benefit remain at less than a paltry $3 billion per year (about $3000 per month per patient).[14] While the FDA has been approving expensive and toxic chemotherapy drugs for cancer of the lung, colon, brain, pancreas, and other nonresponsive tumors, the CMS has been assaulting the Medicare hospice benefit with increased bureaucracy and underfunding. Consequently, the economic pressures on physicians to keep terminally ill patients away from hospice as long as possible are tremendous. As long as Medicare continues providing economic incentives for futile end-of-life treatments and disincentives for hospice care, terminally ill patients will have poor quality living and high cost of dying.


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