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Medicost

Joel Hillman asks how much the public purse should pay for a longer life

Picture taken on January 15, 2012 in Lille, northern France, of drug capsules. AFP PHOTO PHILIPPE HUGUEN (Photo credit should read PHILIPPE HUGUEN/AFP/Getty Images) Picture taken on January 15, 2012 in Lille, northern France, of drug capsules. AFP PHOTO PHILIPPE HUGUEN (Photo credit should read PHILIPPE HUGUEN/AFP/Getty Images)

How much would you pay for an extra year of life? Ten years? One month? My department occasionally gets deliveries of a drug called stiripentol, which the supply company keeps sending to us instead of an adjacent hospital. Stiripentol is used to treat some kinds of epilepsy in children. The reason I’m always so quick to correct these errant deliveries is that each costs about $50,000, and we would otherwise be expected to foot the bill.

Nivolumab and ipilimumab are incredible immune-modulating drugs used to treat some kinds of cancer. Dr Leonard Saltz, a prominent oncologist from the US, estimated in 2015 that the cost of treating Americans with metastatic disease (cancer in more than one place) with this drug combination was USD$174 billion per year. The combination averages a ‘progression-free survival’ of just 11.4 months – less than one year.

The same research found pembrolizumab, a more common member of the same family of drugs, costs somewhere around USD$1 million per melanoma treatment per patient.

The drug sofosbuvir was recently put on the Australian market to treat hepatitis C. Overseas, it’s been hailed as a revolutionary treatment for this formidable virus. It is estimated that, although our Pharmaceutical Benefits Scheme is often able to reduce the price of drugs through deals, it will cost around USD$1,000 per tablet.

These numbers are not at all meant to argue against socialised healthcare, but rather to ask – how much is time worth? And whose time is worth it?

How much would you pay to live an extra year at 21? How much for an extra year at 95? The figures probably differ, which begs the question: what about the quality of the life? If a drug gives you a year, but a year of low quality life, of life in a hospital, should the public purse still pay for it?

There’s a concept called QALY (quality adjusted life years), and the cost-per-QALY per patient is generally considered the metric for how useful a treatment is. USD$50,000 per-QALY-per-patient is generally considered the acceptable threshold, but as much as double that figure has been quoted more recently. In reality, cost-effectiveness data is mostly theoretical and rarely actually married to policy, evidenced by the aforementioned medications. Organisations such as the World Health Organisation recommend 200-300 per cent the per-capita income as the threshold. In Australia, that’s between $160,000 and $240,000.

What about starting a life? In-vitro fertilisation (IVF) in Australia is covered under Medicare, and a motion to restrict subsidies for older women, in whom treatments are exponentially less successful (and more expensive), under then-Health Minister Tony Abbott, was unsuccessful. Recent statistics show that in 2014, less than one-percent of patients over the age of 45 successfully gave birth. This comes out at an average cost of around $200,000 per baby, with these babies more likely to suffer from ill health. Is this effective use of public money?

Recently, the president of the Fertility Society of Australia, Professor Michael Chapman, said it’s time to “think seriously about whether Medicare should cover them”. What are your thoughts when you hear this sum is being gambled on odds the Professor likens to “needing a miracle”?

What about when it starts to look even worse than that? Aflibercept is used to treat some kinds of end stage cancer, and most patients require about 3-4 months of treatment, at about USD$13,000 per month. The benefit? Just 42 days of life.

Is this effective use of public funds? What about the treatments other patients are missing out on as a result? What about bed block and surgery waiting lists?

Forty-two days after multiple rounds of chemotherapy, 42 days of illness, exhaustion, and drug-induced side-effects leading inevitably towards an end. Is this something we should be spending public money on? It’s certainly well outside the range of $50,000 per year.

How much would you pay for an extra month of life? For yourself? For a stranger?