I came across a revealing  post by Dr. Hans Duvefelt on KevinMD discussing the game theory problem created by health insurance where hidden cross-subsidies incentivize individuals to make healthcare decisions that benefit the individual tremendously but are inefficient for the group as a hole. The traditional tragedy of the commons problem. In particular Dr. Duvefelt focuses on an example presented by Dr. Siddhartha Mukherjee of ‘Emperor of All Maladies’ fame in an earlier NYT article, the CV drugs Brilinta and Plavix.

Brilinta, at $6.50 per pill, twice a day, reduces cardiovascular events more than generic Plavix (clopidogrel), which costs 50 cents per pill, once a day. But only by a little: a 20% relative or 2% absolute risk reduction. The event risk was 10% with the more expensive drug and 12% with the one that costs 82% less.

Put differently, if 100 patients were treated with Brilinta for a year, at a cost of $4,680 for each patient, 10 patients would still have an event. With clopidogrel, 100 patients, each one at a cost of $180, 12 events would occur. That means two fewer events would happen per 100 patients on Brilinta at an extra cost of $450,000, or $225,000 per avoided cardiovascular emergency (number needed to treat, NNT=50).

There’s an important error in this back of the napkin calculation because it forgets to factor in the savings created by the avoidance of a cardiovascular event. One study reports that the average initial and follow costs of a cardiovascular event in the US are $16,981 per case, ranging from $6,669 to $56,024. This does not include any non-medical costs that are incurred after a cardiovascular event, including lost productivity, personal utility, etc. Some may say that this is a pedantic criticism of back-of-the-napkin math, but it is necessary to emphasize that there is more to all of this than initially meet’s the eye.

Drs. Duvefelt and Mukherjee thus try to reconcile the ethical conflict between patient welfare and social welfare. What is to be done? Which drug should the physician prescribe? Mukherjee points out the argument that the physician has a responsibility to provide the best care available to the patient. It’s arguable that cost containment is in conflict with the Hippocratic Oath. For Mukherjee the physician can’t do anything, “the solutions are abstract and political”. Dr. Duvefelt points out that although Americans may dislike socialized medicine, ultimately all healthcare where somebody else pays for it, and therefore all health insurance, is by definition “social” and therefore all medicine is social medicine. In his opinion physicians have a responsibility to be stewards and spend resources wisely. But as I said earlier, there’s more to this than meets the eye. Notice anything missing in this entire discussion?

The patient. Both gentlemen are so focused on fixing society that they forget about the patient that they’re supposed to be helping and begin treating him or her as just another input into the medical industrial complex. Gauze, saline, Plavix, patient. The patient no longer has needs, preferences, goals or capacity, they are now merely the vehicle of a disease to be solved efficiently by the system. Social medicine therefore infantilizes the patient in two key ways. The first is that  it strips the patient of agency. Like children that have to do what their parents tell them, the patient now has to follow the decision made between the physician and insurer. What if my insurance covers the more expensive Brilinta, but I would like to make the socially responsible choice and go with Plavix? There are strange people like that out there after all; some even voluntarily pay more in taxes than they have to. What if my insurance only covers the cheaper Plavix, but I want to pay for Brilinta out of pocket? What do I work for after all? Some people work for a bigger house, others for a car, and perhaps I work for better care, even if it’s only 2% better. I don’t get to express my preferences because the system has decided for me. The second way that social medicine infantilizes the patient is by assuming that they are incapable of taking care of themselves. Children don’t have jobs and need to be financially supported by their parents. Similarly social medicine assumes that patients are financially helpless and need to be taken care of by the insurer. Perhaps that’s true for the $4,680 per year Brilanta, but why is that an assumption for the $180 per year Plavix? It’s insulting that the automatic assumption of the healthcare system is that the patient needs insurance to afford this generic. Frankly most people don’t need insurance for a $180 per year prescription, they need it for that $16,891 cardiovascular event we mentioned earlier. Mukherjee mentions the Ashish Jha study that I critiqued in my previous post to discuss the causes of high healthcare expenditure in the US: administrative waste, drug prices, procedure prices. Maybe expenditure wouldn’t be so high if we stopped using health insurance as a healthcare subscription and stopped hiding every single cost, including $180 per year generics, in the premiums?

Drs. Mukherjee’s and Duvefelt’s ask “what is a doctor supposed to do?” How about stop treating their patients like helpless children. Don’t withhold information from them, don’t make decisions for them, don’t assume their resources and circumstances. The patient doesn’t need you to be their parent and they certainly don’t need you to be an efficient steward of economic resources. There is no profound ethical dilemma to be resolved. You work neither for the government nor the insurer, as a physician you work solely for the patient. Explain to them all of their options, give them your recommendation, and let them decide what to do. That’s what a doctor is supposed to do; nothing more, nothing less.