Doctors cannot be expected to be financial engineers

Peggy was in her early 70s and suffered from a terrible lung disease known as pulmonary hypertension. So bad in fact, that she had a pump infusing a medicine under her skin 24 hours a day to keep the blood supply to her lungs open. Once started, this medicine, treprostinil, was known to improve life in those with pulmonary hypertension. Unfortunately, like all continuous infusion medicines of this type, it has the unfortunate side effect of sudden death if stopped for more than 4 hours. Starting it was a difficult choice for Peggy and her expert team of physicians, but her disease had progressed to a point where it was the right decision. As you can imagine, this drug was mighty expensive. We would only find out how expensive later.

On the day that I met Peggy, she was being admitted to the Intensive Care Unit (ICU) not for her pulmonary hypertension, but because she had a bleed in her stomach, which caused her to swallow blood/stomach contents into her already damaged lungs. Once stabilized, our first challenge was to ensure that she continued on the treprostinil. It took a little magic from pharmacy and the drug’s manufacturer, but we were able to get everything together and Peggy was no worse for the wear.

A few days later Peggy was improving, breathing tube out and awake and back to herself. Due to the special nursing needs with treprostinil, Peggy was required to be in the Cardiac Care Unit (CCU), a special type of (ICU), despite her progress. Even though Peggy managed this medicine at home by herself, hospital policy prevented her from transitioning out of the ICU to the general medical floor, at a fraction of the cost. Conceding that point, the decision was made to try and transition Peggy directly to Rehab. But her progress was stalled for one simple reason: treprostinil.

It turns out that if Peggy were to go to a rehab, they have to pay for her medications out of the money they receive to care for her. As it turns out, treprostinil costs $1400 per day. $1400. Now, Peggy does not pay that amount, she has a special arrangement worked out with the company and the state. But in order to make that arrangement work, the company charges full freight for the drug when the patient is institutionalized. Since the drug cost alone would wipe out payment for her stay, no rehab would accept her. So Peggy was stuck in the hospital, and stuck in one of the most specialized and expensive beds in the hospital in the CCU.

Think about that for a moment. A critical care bed was tied up for days for a patient that was well enough to leave the hospital, just not ready to go home. Arbitrage was suggested—would it not make more sense for our hospital to buy the drug for her at rehab, freeing up the CCU bed (which costs far more than daily dose of treprostinil). But we are doctors, not financial engineers. We work in the world of medicines and were unable to orchestrate such an unusual arrangement. So we did the only thing we know how to do. We stopped the expensive medicine.

This was not a financial decision. Peggy had been describing vague body pain, a known side effect of all prostaglandin medicines. Think of treprostinil as a 24-hour infusion of anti-Ibuprofen. Her breathing was actually quite good despite her recent trials in the hospital, so stopping the medicine made medical sense. We monitored her closely during the transition and she quickly improved! She was able to move around more and started on recovery. She was transitioned to a rehab shortly thereafter and continued to improve.

My colleagues’ decision to stop treprostinil was a medical one. But ironically, we would not have considered it if were not for the cost factor of the medicine. Peggy would have gone on for some time on an expensive medicine that was not helping her. At the same time, it was through one party’s insane attempt to “control costs” that simply caused costs to be shifted and multiplied. The entire health care system spent much more on Peggy’s care because no one had the vision or authority to deal with $1400 a day. Pennies compared to the amount wasted, and nothing compared to the risk undertaken by Peggy and her family during this trying time.

Andrew Schutzbank is a physician.

This story was one of the winners of the Costs of Care 2011 healthcare essay contest, with the goal of expanding the national discourse on the role of doctors, nurses, and other care providers in controlling healthcare costs.  These stories from care providers and patients across the nation illustrate everyday opportunities to curb unnecessary and even harmful health care spending on a grassroots level. 

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  • Anonymous

    $1400 a day for medicine? Something is fundamentally wrong with this.

    • Derrick Johnston

      How is it fundamentally wrong that a corporation gets to decide how much to charge for their own products/services?  That’s like saying Apple can’t set the price point for their next iPad.

      A pharma company who risks millions (maybe billions) on drug development, testing, etc (as required by the FDA) should get to decide how much to charge for the medication.  By virtue of their considerable investment they have a right to seek a return (ie profit).  The profit incentive is often why they were willing to accept the risk/cost of drug development in the first place.  This seems particularly important in “orphan” drug development.

      Market forces in action would tend to drive the price down to but unfortunately market forces are no longer really at work in healthcare in the US

      • Anonymous

        Spoken like a true corporate “fat cat.” Maybe I should have said “morally” wrong instead. It is bordering on the fringe of ethical behavior to dangle the carrot of a life-saving in front of a dying patient, then bleeding them financially dry to obtain it. And if they can’t afford it, pharma will bleed the taxpayers dry to make their 500% profit margin. I am not anti-capitalist, but there is a “reasonable” return on your investment, and then there is the US healthcare system.

        • David Bridgeo

          I have to agree with Derrick on this one…  Unless we want to nationalize the
          research, marketing, sale and distribution of pharmaceuticals, then we are
          faced with the reality seen above.  It would seem to me that the more pertinent
          issue is the fragmentation of financial responsibility for a patient’s medical
          care, which often causes perverse decisions to have to be made in order to keep
          the funding flowing. As a practicing physician in Canada, I have seen firsthand
          the effects of government tinkering with drug prices.  Last year in Ontario,
          the government legislated a significant decrease in the prices that could be
          charged by the manufacturer for drugs across the board.  Their move was hailed
          as a major first step in reigning in drug costs, which have been the single
          biggest growth item in our system.  Now, 18 months later, surprise, surprise,
          we are encountering shortages in a wide range of pharmaceuticals, as
          manufacturers discontinue production of items no longer profitable to make. 
          Anyone remember the orphan drug fiascos of the 1970′s?

  • http://twitter.com/KathyAMorelli Kathy Morelli, LPC

    Love those crazy insurance/hospital/expense stories. Worked in a Cancer Center. saw lots of ‘em. who says the system doesnt need fixin?   

  • http://profiles.yahoo.com/u/66NCFAXDWYB7JVNVNLNIUTCUVU Violetta V

    When my mother was in a hospital at a famous cancer center for the infection in her pleural fluid, they said that they could release her home with a nurse managing her IV antibiotics. But.. Medicare doesn’t pay for IV medicines at home. Instead Medicare paid for her stay in this expensive cancer center. Does it make sense for Medicare to refuse to pay for a visiting nurse handling IV medicine when it would save them money on hospital stays?

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