I have a suspicion, based on some of the comments, that some of our aversion is due to the way insurance works (or at least has worked). We see "cost effective" as code for "profitable", because we suspect insurers of caring more about making money than making the best decisions for patients. Which, since the US has for-profit insurers, is a reasonable concern.
Matthew Prorok Aye, that's often how people see it, which is dreadfully ironic, because ignoring cost effectiveness actually makes treatments more expensive (and profitable). It's akin to a store where you aren't allowed to see the price of an item until you've already agreed to purchase it. When no-one (except the manufacturers) can see the cost, that encourages the store to only stock the most expensive and profitable items, and for manufacturers to overcharge and maximize profit margins. Basic economics: Every time someone says, "I want X and I don't care how much it costs." The price goes up.
Hi, I love these videos, but I want to offer my opinion on their production. Studies show that people absorb information well when presented with it in either audio or visual form, but that understanding of presented information decreases when it appears in both audio and visual form concurrently. In other words, when Dr. Carroll is making an important point, instead of putting his script on the screen verbatim, maybe choose to show a list of the most important statistics or concepts in the form of abbreviated notes instead of long-form paragraphs. I think this could help convey the message more effectively and make the videos more aesthetically appealing.
I think the way they're doing that right now is vastly superior to what you suggested. Are you sure the study looked at combined mediums in a way comparable to the video, i.e. to drive key points home, not all the time or something like that?
There's actually been many studies on this effect. It's known as the "redundancy effect," (you can find research on it on many fine sites) and more specifically it states that "learners learn better from pictures and narration than from pictures, narration and on-screen text - especially when that on-screen text is the same as what’s being spoken to them."
I prefer having the full text. As a foreigner I need to look up some of the words. He also talks quickly which doesn't help understanding some of the more complex things he says.
Could you do a video on Catharsis? I've seen some studies that have found that people who vent their anger tend to be happier, but also some other studies that say catharsis doesn't work.
It is a curious blind spot that we react to the idea of "rationing" so reflexively. I can't think of a system that in some way or another doesn't ration and allocate health care. I suppose if we each had our own doctor/surgical staff/operating theater, then we wouldn't be rationing care; I hope no one thinks that's currently possible. We ration care now in part by what kind of job you can get (which determines your insurance for many people), where you choose to/can live (picks which doctors are available and how busy they are), how much deductible/discretionary care you can afford, and so on. If we could somehow get to the point that we can discuss and calmly decide _how_ we ration care, then we could do so _deliberately_ and transparently, rather than the baroque and arcane and continually surprising and underdesigned "system" we have now. I'm curious to know why people think not consciously deciding is better. Or rather, since perhaps this is not a reasoned position but an reflexive moral repugnance, what do people think is the fear that drives it?
The reason people don't want to talk about this topic is because it asks a hard question: "How much do you value human life?" This is a much harder question to answer than: "Do you value human life?" With the latter question, a simple "Yes" means you're not a psychopath. With the former question... it's not so easy. Very few of us want to put a number on the worth of a human life, because it makes us consider the limits of the value of our own life. That isn't a comfortable topic for most people, so we prefer to bury our heads in the sand and not think about it.
Anyone working in a high risk job has their own value for their own life on paper. Their paycheck. Where i live workers in construction get about 120 USD per day for an extra 10.8/100'000 chance of work related death/year. That works out to a negotiated value of $3'000'000'000 for your life. The workers union are pretty good at negotiating it seems. The insurance companies have their own value of a "standard" human life. Different between companies but between 1-2 million USD. But they are the ones that have to pay it. so makes sense that they would value a human lower than someone getting payed.
It's actually really easy to calculate the value of human life. You just look at your given budget, and see how many QALYies you can purchase with it. The most expensive QALYies you can afford IS the cost of human life you can afford. It's not a philosophical question. Do you value human life more? Good, pay more taxes. Do you value it less? Pay less taxes. But with the given funds, it's very easy to determine what society decided human life was worth.
I wonder if the attitude would change if the focus were shifted. Demand effectiveness first, then set cost. In most other industries the cost of a thing is determined by how well it does the job it is designed for.
A question. At 2:36, spending about $26,000 to enjoy 1 QALY with Sovaldi is cost-effective... because? (I.e. what do you compare $26,000 to conclude Sovaldi is cost-effective?)
Even in countries that put a threshold on the amount spent per QALY, you can still get the treatment. Most of the countries that have such restrictions have more or less single-payer systems, which means that treatments are paid for by taxes. So it's perfectly reasonable to put a limit on how much their spending so as to reduce costs overall and save taxpayers money. If you want the treatment in those countries, you simply have to pay for it yourself. Yeah it favors the rich, but the entire point is that the treatment really isn't that effective. It would be like saying that Ferrari's prices favor the rich, sure it's true but it's kinda irrelevant because it's not like everyone needs Ferrari's.
If you're considering paying for a medical procedure to save your life, yeah I'm pretty sure you need it. The Ferrari metaphor breaks down completely here.
Nicholas Wright Well, you may need a car, you don't need that car to be a Ferrari. You may need some medical help, but not the expensive inefficient kind. The metaphor works.
Nicholas Wright Saves your life but you need a machine to breath and you are confined to a chair for the rest of your life. You might be alive but not really living any more and you are taking away a large pile of money from multiple people who could be cured so they life long and full lives.
I totally agree with the arguments made here. I have complete distaste for valuing a life by economic measures. But its a fact of life. I hate how it is impossible to travel faster than light and that teleportation is unlikely to ever work, however that's how our resources to save them are measured and so to work effectively all factors must be calculated in similar units. It is how the Gates foundation helps so many people by putting where its needed most their money for maximum benefit. By ignoring this factor we are not doing the most benefit possible, and the hard calculus shouldn't be thought of as who dies and who lives, but optimising the amount of good we can do with resources we have. I agree that where possible resources should be reallocated and and no hard caps should be set. That's why many agencies that do incorporate this factor don't use it exclusively.
While it may be uncomfortable to talk about (especially for US citizens for some reason), I think any government services MUST consider efficiency. In an ideal world, government can help everyone while subsidising everything. But in reality, your life (or mine) is not any more precious than the life of the person next to us. So if by subsidising my healthcare which may only delay my inevitable death means not being able to save ten others, I think the government should be sensible about this. Perhaps an alternative approach to help me live fuller life before I die is the better one here.
how much error typically surrounds utility values? I ask because cost effectiveness is being calculated as a single number and it would be informative to see how wide the confidence intervals would be around these values. I imagine that responses to time trade off could potentially vary greatly and if so then cost effectiveness is not so easily captured by a single number. Great show btw! One of the most informative TH-cam channels I've ever seen.
Let's say you make insurance categories based on cost effectiveness. The more expensive an insurance is, the more less-cost-effective treatments are covered. So if you're poor, you can get the effective treatments, if you're rich you can get the inefficient treatments too. This is kind of fair, I think. We know we can't cover anyone with full insurance, because it gets really expensive and some won't be able to afford it. Any ideas?
Great video. I remember reading your article in the New York Times about this subject. Unfortunately as a society we pay too much attention to sensationalist stories. If we choose not to treat someone's condition because it's too exorbitantly expensive, they'll make a news story about it and everyone will get angry. But if we do choose to treat it we will have less money to spend for our everyday but still very essential needs, for example providing a low income person with coverage so he could get treatment for his stroke. Our lifespans are getting longer and there is literally not going to be enough money to cover every treatment available.
Are QALYs agnostic to the type of condition and the type of treatment? When someone gets 5 QALYs from X treatment for Y disease, and someone else also gets 5 QALYs for V treatment for W disease, do each of those 5 QALYs have inherently the same meaning?
People always seem to forget that if you don't take cost effectiveness into question, you're neglecting to help people. It's like, no one wants to say it's not worth $1,000,000 to extend grandma's life by another year, because they're only looking at the one person--grandma. What they're not thinking about is how that same money can go towards helping many other people get many more years--and not just years, but quality years. When you refuse to use the math, you're neglecting the bigger picture and neglecting a lot of other people in the process, by your unwillingness to say that there are limits to what you ought to be willing to spend money on. You can, and should, quantify these things, in order to help optimize human well-being and minimize human suffering. If you refuse to do that, you just make things ineffecient and poorly distribute health care.
Why? Some treatments are not worth the money. After all, would you like your premiums to go up so that someone can et an extra year of life for a billion dollars? Isn't it selfish to allocate so many resources to something that doesn't work? After all, what if 1000 people have to be denied healthcare so that one person could live one more month or so?
When a society has free healthcare (paid for by taxpayers), there must be a balance between quality and length of life. What percent of your yearly salary would you give up (along with everyone else) so that everyone lives an extra year? Unless your answer is 100%, then you are considering cost-effectiveness. Although you shouldn't make all of your decisions based on cost-effectiveness, it is important to at least consider it.
Rather than thinking about it in terms of aunt agnes not getting her lung cancer drugs think of it this way, If we stopped paying for every horny old guys boner pills how many more dialysis machines could we buy? Edit: Quick search show the $/QALY on viagra to be around 11-12k for reference. This is however because Viagra is $5-$10 per pill. which shows the flip side of cost effectiveness, if it is calculated (as it once was by insurers who would not cover it at higher costs) and shows too high a cost it puts pressure on producers to drop the cost. You know that whole invisible hand thing that usually is so mucked up with health care that is rarely optional.
In the UK any treatment that costs more than £20k per QALY, which is just under $31, is illegal on the NHS and if you want such treatments you must go to private healthcare.
Cost effectiveness medical care seems like a really good information to have. It is true that we cannot put a value on life, but with limited resources(Govt funds), I'd rather the treatment goes to someone with a higher QALY.
With a single-payer system with a reasonable cost-effectiveness limit, Pharma companies are encouraged to develop treatments that either a) significantly improve quality of life for expensive treatments or b) are less effective but cheaper. Expensive treatments that don't do much just won't get funded. You can also flip the argument. A lot of treatments aren't covered by private health insurance as they are "too expensive", unless you have gold-plated plans that cost a fortune. If those expensive treatments are actually really effective in improving quality of life (thus low cost per QUALY), in a system viewing cost-effectiveness rather than absolute cost they would actually get covered when they otherwise wouldn't. So people saying "your life isn't worth enough". You get that already with private health insurers who will cut you off if your treatment costs get too high. They are saying is "this treatment isn't good enough for what it costs".
Glad to these arguments being put out there. Recently had a discussion with my dad (we're Australian so different perspective) and to him the concept of cost effectiveness seemed akin to putting a price on life. This isn't the case though. Medicine faces the same economic limits that any other field does. There are infinite demands for limited resources (mainly manufacturing & specialised skill). If we don't consider cost effectiveness then it will lead to inefficiencies which in turn leads to worse outcomes. Cost effectiveness in medicine shouldn't have the image it does.
Putting a price on human health and life makes me uncomfortable. However, it's true that we value the time and energy that researchers pour into their undergraduate degrees and PhDs, then the research carried out to come up with treatments, the cost of resources and processes required to produce treatments, all of the trials, and distribution of treatments. It's clear that all of the people involved in the production and distribution of a treatment should be paid for their time and energy the same way we're willing to pay for everyone's time and effort from teachers to miners to waiters. Since it's inevitable that the way our society works, treatments will cost money, as a patient I'd like to know how worthwhile my treatment is. Perhaps in a post-scarcity world treatments will be free but with things as they are now, the best I can do is stay informed and try to make sensible decisions.
Cost effectiveness is one thing and I get that we shouldn't waste money unnecessarily, but I think the real problem stems from the fact that price-negotiation seems all sorts of messed up. I'd REALLY like to know how much money is spent across the board for any given drug and where that research money came from and how long it will take to reasonably pay off the expenses. And after that, how much does it cost to manufacture in all terms, from raw materials to final product. All these hypothetical thoughts would also take into account wages and other overhead. So if a drug has been on the market and is paid off, and it costs $0.10 to make is it really necessary to continue to charge $4,000 for a 30 day supply? Treatment costs so much simply because it can and people will pay basically anything, even have their lives continually ruined by the inability to pay medical bills and declare bankruptcy, to stay alive. I get the fact that there's no free lunch and of course people should get paid for working...but when is enough enough? We all want to be rich but we all want our money to ourselves. So then we fight and bitch and moan to ensure our taxes benefit us DIRECTLY with little regard for the rest of the nation as a cohesive entity. So we're all greedy money-grubbers until we find ourselves chronically ill through no fault of our own THEN we sing a different tune. is throwing money at a problem going to solve it? Of course not. But we're talking about one evaluation that SHOULD NOT be the sole indicator of who receives treatment and who doesn't.
I'm a student and pharmacy and I can tell you where the cost comes from (at least in Canada). A pill costs fractions of cents. It can be mass produced and really has almost no cost. What you pay for is the very demanding research protocols and standards to prove the drug's efficiency, the close monitoring of the drug-making instalations and the very high sanity standards, and the pharmacist's service as a drug specialist, who keeps your files, analyses them rigourously for potential dangers and insures that someone knows what you take, and why. (Out of 100 prescriptions, doctors will accidentally change the dose or mess up something 1-3 times. Every day we solve problems). Also the pharmacist insures that you get actually what you are prescribed. You try to read a prescription and aquire it from a manifacturer, then keep it in standardised conditions. But yeah, very expensive drugs (recombinant antibodies and stuff) are actually very expensive to make and research, and only get sold to a couple thousands of patients. By the way the "Big pharma" research industry is really not something you should invest in. They don't "swim in billions of dollars" as the polular culture describes them. They've had a pretty rough decade.
GregTom2 my dad worked for "Big Pharma" here in New Jersey for many years. I think part of the reason why they've had it so rough is the outright wasteful spending they've been doing. If you could see the amount of...presents...given out to employees, doctors, marketing staff, and everywhere else they skipped along to, you would quite literally barf. It got so bad that thankfully the US Federal Government stepped in and required all gift transactions to be public information. Honestly, it's nice to see a doctor's office full of patients and not sales people pitching new drugs, and in some instances literally getting into fights at the counter. I'm well aware that research comes with a huge price tag, especially when research leads to dead ends or compounds that have a great effect but have a high probability of killing the patient; big risk but potentially big reward. I take a very unpopular stance since personal wealth is something Americans don't like to hear mentioned and they assume the government is going to "steal my money", but if you're making, let's make up some numbers here, $50,000,000 a year in pay (I'm just going to lump everything together...regular negotiated salary, bonuses, etc.) as the head of a major pharmaceutical...isn't that extreme? Even if you took home $10,000,000 you'd still live a massively comfortable lifestyle, and I suspect that not much would change at all, leaving the other 40 million to reinvest into further research. Human greed, I'm convinced, has brought us to this point...
Christopher Sadlowski Stock-holders in general do expect dividents to be payed, and this is how the owner makes money. Of course the president has a sallary, but I would be shocked if it were over 3 millions per year. And the amount of wealth generated to be given as dividents or kept as capitals is not very good. And the gifts they gave; while outrageous and indeed illegal, were a form of advertising, which in the end increased their profit. The reason why it doesn't go so well is that there's already a cure to the most common diseases. Now you need to invest the same in research to help 1-2% of the population, instead of 30-40%
In Australia we only fund drugs through medicare (through our Pharmaceutical Benefits Scheme) when the medication can be proven to be cost-effective. I think it's a good system and it's worked (pretty well) so far :) Sovaldi was just knocked back though recently so no one is currently using it in Australia unless they can afford the whole treatment.
Wow. This is a tough issue. I think with the framing of increasing public health measures and greater costs incurred by the government/taxpayers I think I agree in saying that its like burying our heads in the sand to not consider the effectiveness of a treatment. It reminds me of the issue with the elderly who in some cases undergo invasive surgery in an effort to extend life but who suffer greatly or die because of it due to their bodies not being able to take the stress of that surgery. These cases would be an example of the non cost effective treatments that medicare would not pay for in order to allocate to more effective treatments for others.
It sounds harsh, but it's true that cost per QALY needs to be taken into account. We can and need to put a cost on life because the system isn't sustainable as it is. There are a lot of factors that would go into that, but one of the major ones should be the quality of the person in question. A criminal who's in jail with no chance of parole shouldn't merit the same QALY as a teacher, police office, firefighter, etc.
Diana Peña Not really. It's based directly on the utility that the individual has for society. Of course, this then means that with regards to free healthcare a doctor should get more than a police officer and then a police officer more than a mcdonalds worker. Sounds immoral, but tbh I don't think it is. Why would it be immmoral? Because it is unfair? But isn't just as unfair to let a random person die out of the two?
While I think that cost per QALY (and cost-effectiveness in general) needs to be taken into account, that has and should have no relation to "the quality of the person in question." For one, that's something extremely subjective, and it adds ethical concerns and discrimination to an issue that already makes some squirm. Who are we to say who deserves an extra year of healthy life over another? Considering a treatment more cost-effective when the life we're saving or improving is more valuable to society is morally grey at best. Furthermore, QALY is a fairly objective measure that has nothing to do with how much the person in question accomplishes for society in their remaining years of life, but how healthy they are during those years. Thus determining QALY differently per person rather than per treatment would really only discriminate against those with multiple conditions, since treatment couldn't bring them to full health. To use the imaginary cure for moderate seizure disorder as an example, imagine that there are two patients: Patient A has only moderate seizure disorder, while Patient B has both moderate seizure disorder and Type 1 diabetes. Using QALY as Dr. Carroll describes would consider only the effectiveness of the treatment in question over the general population of people with moderate seizure disoder; thus, if it was considered a cost-effective treatment for one patient, it would be considered cost-effective for all. However, if we were to instead calculate the QALY based on how the treatment would affect each patient, Patient A's treatment would be considered far more cost-effective than Patient B's by far, since Patient A would be returned to full health while Patient B would still have Type 1 diabetes. It would essentially be saying that the life of someone with Type 1 diabetes (or any other condition that cannot be cured) is worth less than that of someone in perfect health, and I hope you're able to see the ethical problems with that. Cost-effectiveness shouldn't be ignored, but we need to recognize the thin ethical line we're treading on and how easily it is to slip into dangerously immoral mentalities.
Ryan Hutton how do you objectively judge a person's value though? Is a nurse worth more than a physio? Is a McDonalds worker worth more or less than a Walmart employee? Is an artist worth more or less than a bin man? Is someone who is currently unemployed worth less than a long term unemployed person who currently has a job? Who judges what is "useful" to society? Why does someone have to conform to what society wants them to be just to survive? If you start not treating convicts too, you're getting into the realms of unjustified death penalty. What if the felon is falsely imprisoned? (Not uncommon). What if the crime is trivial? Do they deserve less of a shot at life? What if it's a crime that shouldn't really be a crime in the first place? (Laws change all the time) If you're american (or from numerous other countries where the same is true) what about the way the judicial system unfairly targets minorities? You're stumbling into the realm of accidental ethnic cleansing. Selective treatment throws up all sorts of awkward questions that have no clear answers.
***** I'm not saying don't treat convicts at all. I'm saying don't be willing to spend as much on them. They won't all drop dead from that at the age of 50. You judge someone's value based on their societal utility. This is largely shown by their wage however many jobs are underpaid because they are enjoyable and "fun" to do in certain ways to certain people - policing and teaching are fine examples of such and so those people would have to be weighted slightly higher than their wage would suggest. Jobs like train drivers are often slightly over-valued because even though it doesn't have gigantic utility considering how easy it is to do compared to other jobs it is boring as hell and so few want to do it. Of course then you have to get into the whole valuing a person's future possible utility and frankly it would get too complex to be practical - monitoring their education, their other health needs be it physical or mental, their age and so on. I don't think the fact that people are criminals itself is reason to be less willing to spend lots of $$$ on their health. So the thing about "what if laws change" is irrelevant. The reason why I would be less willing to spend money on their health is because they have a reduced likely future utility because of their criminal record which means they are more likely than a normal person to commit more crime and also will struggle with getting many different jobs.
If only there weren't some federal law requiring us to buy a specific kind of health insurance, people could feel free to purchase coverage that only covered specific levels of QALY.
Everyone's risk of death due to cancer would decrease if the government paid for monthly screenings of literally everyone for cancer? Do the people who have issues with this video believe we should do that then? Hopefully your answer is: "No, that would be ridiculously expensive and we can't afford it and even if we could we should be spending that money more efficiently on other healthcare services."
It sucks that we have to talk about cost effectiveness in life or death situations. It really does. Nobody likes that! It's called "limited ressources" or "reality", whichever you prefer. We have to set a price limit somewhere. Anyone denying that is being undeniably irrational. Think a drug that costs 1 billion $ for 1 extra day. As soon as you agree that this drug should NOT be covered then you agree that we should be talking about cost effectiveness.
$10,000,000/QALY is pretty fucking great if you force your neighbor at the point of a gun to pay for it and you have absolutely no intentions of paying for it (aka Obamacare). I wonder if Healthcare Triage will have the balls to dissect every one of the 2000 page Obamacare bill and tell us how fucking awesome it is?
Wait what. What do you mean Americans dont take cost effectiveness into account?? What the hell. that sounds positively evil to me??? So what you just...guess??? what about resource allocation?? HOW IS THAT OK AT ALL?
i dont understand how cost effectiveness isnt considered??? cost effectiveness and resource allocation is a really important part of public health???? im so confused. what. is america even real
Think about it this way. If we spend the money on one person for something that doesn't work, many more would have to go without. It's like spending a million dollars on a crumb to feed one person instead of using that money to buy whole food for everyone. Therefore, by not considering money, we're hurting more people. I know your appeal is very emotional, but that's all it is. Emotion.
Let me put it this way. If you and 999 other people were starving to death, and you had a finite amount of money, would you rather blow it all on a grain of rice to make one person feel better, but not helped at all, or would you rather save 999 people instead?
Diana Peña you assume that there is a limited amount of healthcare to go around, which is not the case. Also, you assume that i'm advocating crumbs, instead of measurable benefits to patients. furthermore, you seem to not fully understand the separation between a physician and an insurance company. a physician should, as the oath states, always fight to apply all measures which are required for the benefit of the sick *not* "apply all measures that are required for the benefit of this sick unless you think it's too expensive." the insurance company took no such oath so they can make such a decision. A physician who advocates cost effectiveness in the absence of shortages is a disgrace. there was nothing emotional about my statement. he did take that oath, he is breaking it by advocating cost effectiveness, and it is a shame. your appeal assumes a lot and is very inaccurate, but that's all it is. assumption and inaccuracy.
The original Hippocratic oath also prohibits abortion, so I don't know how much doctors stick to that oath anymore. plus abortion results in probably about -70ish QALYs.
I don't like this way of looking at healthcare. I know they have to make money and they have to be smart with their money but putting a price on someone's life just seems wrong to me. If someone wants a treatment to save their life and they are 90 years old then I say they should have their autonomous decision and receive that treatment. You can't put a price on how many years a person has left and having money decide whether someone is going to live or die or in other words who is more qualified to live is just sickening to me. Again I understand that there is a limited amount of resources such as money but it is so sad that this is what our lives can potentially come down to.
This video has not aged well in our current political climate. Cost effectiveness is important, but also incredibly tone def to discuss in our current dilemma with CHIP defunded and medicaid on the chopping block. I have always appreciated your partisan tone, but discussing health care cost effectiveness is disturbing, and quite frankly infuriating, when we humor the $4,000 "price" for a month of prescription medication as "fair" and the system that denied it to her, including women's suffrage, as "fair". Neither was fair. Sometimes being called naive is unfair, but when people are dying and we're told to learn from it cheerfully... No sir, we should protest every moment of unfairness we can possibly perceive because most people cannot see how their lives have been toyed with by cruel people, indifferent to our suffering with more wealth and power than you or I could imagine. Don't facilitate their greed or the deaths of poor people even for a moment. NOT even for an important topic like cost effectiveness.
I feel like the amount of money and number of yours left to live should not determine if a person can receive a treatment. Life is greater than any amount of money there is to offer. If some one is elderly and wants a treatment to save them, they should be able to receive it no matter what.
+Deli Cee This is the sort of crap the industry wants you to think so they can squeeze every last penny out of you! By trying to make it seem like a choice between the materialistic option (keeping your money) or the nice, healthy, moral option (giving up money, and thus a more material life, for a healthy life for you and your loved ones), the healthcare industry is ironically just brainwashing you so you give them all your money for limited results. This isn't some crazy conspiracy theory, I say this as a chemistry student who may well end up making/developing drugs in the EU. I just find it disgusting how in the US they brainwash you, so effectively the customer ends up ripping themselves off because they think that's the only way they can do it! It's a seriously twisted situation when you think about it.
I have a suspicion, based on some of the comments, that some of our aversion is due to the way insurance works (or at least has worked). We see "cost effective" as code for "profitable", because we suspect insurers of caring more about making money than making the best decisions for patients. Which, since the US has for-profit insurers, is a reasonable concern.
Matthew Prorok Aye, that's often how people see it, which is dreadfully ironic, because ignoring cost effectiveness actually makes treatments more expensive (and profitable).
It's akin to a store where you aren't allowed to see the price of an item until you've already agreed to purchase it. When no-one (except the manufacturers) can see the cost, that encourages the store to only stock the most expensive and profitable items, and for manufacturers to overcharge and maximize profit margins.
Basic economics: Every time someone says, "I want X and I don't care how much it costs." The price goes up.
Hi, I love these videos, but I want to offer my opinion on their production. Studies show that people absorb information well when presented with it in either audio or visual form, but that understanding of presented information decreases when it appears in both audio and visual form concurrently. In other words, when Dr. Carroll is making an important point, instead of putting his script on the screen verbatim, maybe choose to show a list of the most important statistics or concepts in the form of abbreviated notes instead of long-form paragraphs. I think this could help convey the message more effectively and make the videos more aesthetically appealing.
Excellent suggestions. The paragraph stuff always confused me.
I think the way they're doing that right now is vastly superior to what you suggested. Are you sure the study looked at combined mediums in a way comparable to the video, i.e. to drive key points home, not all the time or something like that?
There's actually been many studies on this effect. It's known as the "redundancy effect," (you can find research on it on many fine sites) and more specifically it states that "learners learn better from pictures and narration than from pictures, narration and on-screen text - especially when that on-screen text is the same as what’s being spoken to them."
I prefer having the full text. As a foreigner I need to look up some of the words. He also talks quickly which doesn't help understanding some of the more complex things he says.
I see it as a form of closed captioning but prettier.
Could you do a video on Catharsis? I've seen some studies that have found that people who vent their anger tend to be happier, but also some other studies that say catharsis doesn't work.
It is a curious blind spot that we react to the idea of "rationing" so reflexively. I can't think of a system that in some way or another doesn't ration and allocate health care. I suppose if we each had our own doctor/surgical staff/operating theater, then we wouldn't be rationing care; I hope no one thinks that's currently possible. We ration care now in part by what kind of job you can get (which determines your insurance for many people), where you choose to/can live (picks which doctors are available and how busy they are), how much deductible/discretionary care you can afford, and so on. If we could somehow get to the point that we can discuss and calmly decide _how_ we ration care, then we could do so _deliberately_ and transparently, rather than the baroque and arcane and continually surprising and underdesigned "system" we have now. I'm curious to know why people think not consciously deciding is better.
Or rather, since perhaps this is not a reasoned position but an reflexive moral repugnance, what do people think is the fear that drives it?
The reason people don't want to talk about this topic is because it asks a hard question:
"How much do you value human life?"
This is a much harder question to answer than:
"Do you value human life?"
With the latter question, a simple "Yes" means you're not a psychopath. With the former question... it's not so easy. Very few of us want to put a number on the worth of a human life, because it makes us consider the limits of the value of our own life. That isn't a comfortable topic for most people, so we prefer to bury our heads in the sand and not think about it.
Anyone working in a high risk job has their own value for their own life on paper. Their paycheck. Where i live workers in construction get about 120 USD per day for an extra 10.8/100'000 chance of work related death/year. That works out to a negotiated value of $3'000'000'000 for your life. The workers union are pretty good at negotiating it seems.
The insurance companies have their own value of a "standard" human life. Different between companies but between 1-2 million USD. But they are the ones that have to pay it. so makes sense that they would value a human lower than someone getting payed.
It's actually really easy to calculate the value of human life. You just look at your given budget, and see how many QALYies you can purchase with it. The most expensive QALYies you can afford IS the cost of human life you can afford.
It's not a philosophical question. Do you value human life more? Good, pay more taxes. Do you value it less? Pay less taxes. But with the given funds, it's very easy to determine what society decided human life was worth.
GregTom2 Crawling in my skin, these wounds they will not heal, fear is how I fall - comfusing what is real
FlowersAndFoxes what?
GregTom2 Don't make eye
contact. Maybe it will go away. >.>
I'm a physician who is attending an MSc in health economics and your videos help immensely! thank you very much!
I wonder if the attitude would change if the focus were shifted. Demand effectiveness first, then set cost. In most other industries the cost of a thing is determined by how well it does the job it is designed for.
A question. At 2:36, spending about $26,000 to enjoy 1 QALY with Sovaldi is cost-effective... because? (I.e. what do you compare $26,000 to conclude Sovaldi is cost-effective?)
Even in countries that put a threshold on the amount spent per QALY, you can still get the treatment. Most of the countries that have such restrictions have more or less single-payer systems, which means that treatments are paid for by taxes. So it's perfectly reasonable to put a limit on how much their spending so as to reduce costs overall and save taxpayers money. If you want the treatment in those countries, you simply have to pay for it yourself. Yeah it favors the rich, but the entire point is that the treatment really isn't that effective. It would be like saying that Ferrari's prices favor the rich, sure it's true but it's kinda irrelevant because it's not like everyone needs Ferrari's.
Thank you!
If you're considering paying for a medical procedure to save your life, yeah I'm pretty sure you need it. The Ferrari metaphor breaks down completely here.
Nicholas, what if the treatment doesn't work?
Nicholas Wright
Well, you may need a car, you don't need that car to be a Ferrari. You may need some medical help, but not the expensive inefficient kind. The metaphor works.
Nicholas Wright Saves your life but you need a machine to breath and you are confined to a chair for the rest of your life. You might be alive but not really living any more and you are taking away a large pile of money from multiple people who could be cured so they life long and full lives.
I totally agree with the arguments made here. I have complete distaste for valuing a life by economic measures. But its a fact of life. I hate how it is impossible to travel faster than light and that teleportation is unlikely to ever work, however that's how our resources to save them are measured and so to work effectively all factors must be calculated in similar units.
It is how the Gates foundation helps so many people by putting where its needed most their money for maximum benefit. By ignoring this factor we are not doing the most benefit possible, and the hard calculus shouldn't be thought of as who dies and who lives, but optimising the amount of good we can do with resources we have. I agree that where possible resources should be reallocated and and no hard caps should be set. That's why many agencies that do incorporate this factor don't use it exclusively.
While it may be uncomfortable to talk about (especially for US citizens for some reason), I think any government services MUST consider efficiency. In an ideal world, government can help everyone while subsidising everything. But in reality, your life (or mine) is not any more precious than the life of the person next to us. So if by subsidising my healthcare which may only delay my inevitable death means not being able to save ten others, I think the government should be sensible about this. Perhaps an alternative approach to help me live fuller life before I die is the better one here.
What are some of the cost effectiveness policies in other countries?
how much error typically surrounds utility values? I ask because cost effectiveness is being calculated as a single number and it would be informative to see how wide the confidence intervals would be around these values. I imagine that responses to time trade off could potentially vary greatly and if so then cost effectiveness is not so easily captured by a single number. Great show btw! One of the most informative TH-cam channels I've ever seen.
Let's say you make insurance categories based on cost effectiveness. The more expensive an insurance is, the more less-cost-effective treatments are covered. So if you're poor, you can get the effective treatments, if you're rich you can get the inefficient treatments too. This is kind of fair, I think. We know we can't cover anyone with full insurance, because it gets really expensive and some won't be able to afford it. Any ideas?
Can you do an episode comparing the maternal care in different countries?
Great video. I remember reading your article in the New York Times about this subject. Unfortunately as a society we pay too much attention to sensationalist stories. If we choose not to treat someone's condition because it's too exorbitantly expensive, they'll make a news story about it and everyone will get angry. But if we do choose to treat it we will have less money to spend for our everyday but still very essential needs, for example providing a low income person with coverage so he could get treatment for his stroke. Our lifespans are getting longer and there is literally not going to be enough money to cover every treatment available.
Are QALYs agnostic to the type of condition and the type of treatment?
When someone gets 5 QALYs from X treatment for Y disease, and someone else also gets 5 QALYs for V treatment for W disease, do each of those 5 QALYs have inherently the same meaning?
People always seem to forget that if you don't take cost effectiveness into question, you're neglecting to help people. It's like, no one wants to say it's not worth $1,000,000 to extend grandma's life by another year, because they're only looking at the one person--grandma. What they're not thinking about is how that same money can go towards helping many other people get many more years--and not just years, but quality years. When you refuse to use the math, you're neglecting the bigger picture and neglecting a lot of other people in the process, by your unwillingness to say that there are limits to what you ought to be willing to spend money on. You can, and should, quantify these things, in order to help optimize human well-being and minimize human suffering. If you refuse to do that, you just make things ineffecient and poorly distribute health care.
Usually I agree with you completely. But with this one, I can see why people are concerned.
Why? Some treatments are not worth the money. After all, would you like your premiums to go up so that someone can et an extra year of life for a billion dollars? Isn't it selfish to allocate so many resources to something that doesn't work? After all, what if 1000 people have to be denied healthcare so that one person could live one more month or so?
When a society has free healthcare (paid for by taxpayers), there must be a balance between quality and length of life. What percent of your yearly salary would you give up (along with everyone else) so that everyone lives an extra year? Unless your answer is 100%, then you are considering cost-effectiveness. Although you shouldn't make all of your decisions based on cost-effectiveness, it is important to at least consider it.
Rather than thinking about it in terms of aunt agnes not getting her lung cancer drugs think of it this way, If we stopped paying for every horny old guys boner pills how many more dialysis machines could we buy?
Edit: Quick search show the $/QALY on viagra to be around 11-12k for reference. This is however because Viagra is $5-$10 per pill. which shows the flip side of cost effectiveness, if it is calculated (as it once was by insurers who would not cover it at higher costs) and shows too high a cost it puts pressure on producers to drop the cost. You know that whole invisible hand thing that usually is so mucked up with health care that is rarely optional.
In the UK any treatment that costs more than £20k per QALY, which is just under $31, is illegal on the NHS and if you want such treatments you must go to private healthcare.
Cost effectiveness medical care seems like a really good information to have.
It is true that we cannot put a value on life, but with limited resources(Govt funds), I'd rather the treatment goes to someone with a higher QALY.
With a single-payer system with a reasonable cost-effectiveness limit, Pharma companies are encouraged to develop treatments that either a) significantly improve quality of life for expensive treatments or b) are less effective but cheaper. Expensive treatments that don't do much just won't get funded.
You can also flip the argument. A lot of treatments aren't covered by private health insurance as they are "too expensive", unless you have gold-plated plans that cost a fortune. If those expensive treatments are actually really effective in improving quality of life (thus low cost per QUALY), in a system viewing cost-effectiveness rather than absolute cost they would actually get covered when they otherwise wouldn't.
So people saying "your life isn't worth enough". You get that already with private health insurers who will cut you off if your treatment costs get too high. They are saying is "this treatment isn't good enough for what it costs".
It's amazing, given that our hyper-capitalistic society will put a price tag on a person's self-worth, that we shy away from putting a price on life.
Glad to these arguments being put out there. Recently had a discussion with my dad (we're Australian so different perspective) and to him the concept of cost effectiveness seemed akin to putting a price on life.
This isn't the case though. Medicine faces the same economic limits that any other field does. There are infinite demands for limited resources (mainly manufacturing & specialised skill). If we don't consider cost effectiveness then it will lead to inefficiencies which in turn leads to worse outcomes. Cost effectiveness in medicine shouldn't have the image it does.
Putting a price on human health and life makes me uncomfortable. However, it's true that we value the time and energy that researchers pour into their undergraduate degrees and PhDs, then the research carried out to come up with treatments, the cost of resources and processes required to produce treatments, all of the trials, and distribution of treatments. It's clear that all of the people involved in the production and distribution of a treatment should be paid for their time and energy the same way we're willing to pay for everyone's time and effort from teachers to miners to waiters.
Since it's inevitable that the way our society works, treatments will cost money, as a patient I'd like to know how worthwhile my treatment is. Perhaps in a post-scarcity world treatments will be free but with things as they are now, the best I can do is stay informed and try to make sensible decisions.
Cost effectiveness is one thing and I get that we shouldn't waste money unnecessarily, but I think the real problem stems from the fact that price-negotiation seems all sorts of messed up. I'd REALLY like to know how much money is spent across the board for any given drug and where that research money came from and how long it will take to reasonably pay off the expenses. And after that, how much does it cost to manufacture in all terms, from raw materials to final product. All these hypothetical thoughts would also take into account wages and other overhead. So if a drug has been on the market and is paid off, and it costs $0.10 to make is it really necessary to continue to charge $4,000 for a 30 day supply? Treatment costs so much simply because it can and people will pay basically anything, even have their lives continually ruined by the inability to pay medical bills and declare bankruptcy, to stay alive. I get the fact that there's no free lunch and of course people should get paid for working...but when is enough enough? We all want to be rich but we all want our money to ourselves. So then we fight and bitch and moan to ensure our taxes benefit us DIRECTLY with little regard for the rest of the nation as a cohesive entity. So we're all greedy money-grubbers until we find ourselves chronically ill through no fault of our own THEN we sing a different tune. is throwing money at a problem going to solve it? Of course not. But we're talking about one evaluation that SHOULD NOT be the sole indicator of who receives treatment and who doesn't.
I'm a student and pharmacy and I can tell you where the cost comes from (at least in Canada). A pill costs fractions of cents. It can be mass produced and really has almost no cost. What you pay for is the very demanding research protocols and standards to prove the drug's efficiency, the close monitoring of the drug-making instalations and the very high sanity standards, and the pharmacist's service as a drug specialist, who keeps your files, analyses them rigourously for potential dangers and insures that someone knows what you take, and why. (Out of 100 prescriptions, doctors will accidentally change the dose or mess up something 1-3 times. Every day we solve problems). Also the pharmacist insures that you get actually what you are prescribed. You try to read a prescription and aquire it from a manifacturer, then keep it in standardised conditions.
But yeah, very expensive drugs (recombinant antibodies and stuff) are actually very expensive to make and research, and only get sold to a couple thousands of patients.
By the way the "Big pharma" research industry is really not something you should invest in. They don't "swim in billions of dollars" as the polular culture describes them. They've had a pretty rough decade.
GregTom2 my dad worked for "Big Pharma" here in New Jersey for many years. I think part of the reason why they've had it so rough is the outright wasteful spending they've been doing. If you could see the amount of...presents...given out to employees, doctors, marketing staff, and everywhere else they skipped along to, you would quite literally barf. It got so bad that thankfully the US Federal Government stepped in and required all gift transactions to be public information. Honestly, it's nice to see a doctor's office full of patients and not sales people pitching new drugs, and in some instances literally getting into fights at the counter. I'm well aware that research comes with a huge price tag, especially when research leads to dead ends or compounds that have a great effect but have a high probability of killing the patient; big risk but potentially big reward. I take a very unpopular stance since personal wealth is something Americans don't like to hear mentioned and they assume the government is going to "steal my money", but if you're making, let's make up some numbers here, $50,000,000 a year in pay (I'm just going to lump everything together...regular negotiated salary, bonuses, etc.) as the head of a major pharmaceutical...isn't that extreme? Even if you took home $10,000,000 you'd still live a massively comfortable lifestyle, and I suspect that not much would change at all, leaving the other 40 million to reinvest into further research. Human greed, I'm convinced, has brought us to this point...
Christopher Sadlowski Stock-holders in general do expect dividents to be payed, and this is how the owner makes money. Of course the president has a sallary, but I would be shocked if it were over 3 millions per year.
And the amount of wealth generated to be given as dividents or kept as capitals is not very good.
And the gifts they gave; while outrageous and indeed illegal, were a form of advertising, which in the end increased their profit.
The reason why it doesn't go so well is that there's already a cure to the most common diseases. Now you need to invest the same in research to help 1-2% of the population, instead of 30-40%
In Australia we only fund drugs through medicare (through our Pharmaceutical Benefits Scheme) when the medication can be proven to be cost-effective. I think it's a good system and it's worked (pretty well) so far :) Sovaldi was just knocked back though recently so no one is currently using it in Australia unless they can afford the whole treatment.
Will the aluminium in my anti perspiring deodorant make me more likely to get cancer?
For some reason, I feel like Aaron in this episode looks like he belongs in The Division. And it's not just the hoodie; it's a combination of things.
Wow. This is a tough issue. I think with the framing of increasing public health measures and greater costs incurred by the government/taxpayers I think I agree in saying that its like burying our heads in the sand to not consider the effectiveness of a treatment. It reminds me of the issue with the elderly who in some cases undergo invasive surgery in an effort to extend life but who suffer greatly or die because of it due to their bodies not being able to take the stress of that surgery. These cases would be an example of the non cost effective treatments that medicare would not pay for in order to allocate to more effective treatments for others.
It sounds harsh, but it's true that cost per QALY needs to be taken into account. We can and need to put a cost on life because the system isn't sustainable as it is.
There are a lot of factors that would go into that, but one of the major ones should be the quality of the person in question. A criminal who's in jail with no chance of parole shouldn't merit the same QALY as a teacher, police office, firefighter, etc.
Well, that second one seems to be going too far. Seems fairly arbitrary.
Diana Peña Not really. It's based directly on the utility that the individual has for society. Of course, this then means that with regards to free healthcare a doctor should get more than a police officer and then a police officer more than a mcdonalds worker. Sounds immoral, but tbh I don't think it is. Why would it be immmoral? Because it is unfair? But isn't just as unfair to let a random person die out of the two?
While I think that cost per QALY (and cost-effectiveness in general) needs to be taken into account, that has and should have no relation to "the quality of the person in question." For one, that's something extremely subjective, and it adds ethical concerns and discrimination to an issue that already makes some squirm. Who are we to say who deserves an extra year of healthy life over another? Considering a treatment more cost-effective when the life we're saving or improving is more valuable to society is morally grey at best.
Furthermore, QALY is a fairly objective measure that has nothing to do with how much the person in question accomplishes for society in their remaining years of life, but how healthy they are during those years. Thus determining QALY differently per person rather than per treatment would really only discriminate against those with multiple conditions, since treatment couldn't bring them to full health. To use the imaginary cure for moderate seizure disorder as an example, imagine that there are two patients: Patient A has only moderate seizure disorder, while Patient B has both moderate seizure disorder and Type 1 diabetes. Using QALY as Dr. Carroll describes would consider only the effectiveness of the treatment in question over the general population of people with moderate seizure disoder; thus, if it was considered a cost-effective treatment for one patient, it would be considered cost-effective for all. However, if we were to instead calculate the QALY based on how the treatment would affect each patient, Patient A's treatment would be considered far more cost-effective than Patient B's by far, since Patient A would be returned to full health while Patient B would still have Type 1 diabetes. It would essentially be saying that the life of someone with Type 1 diabetes (or any other condition that cannot be cured) is worth less than that of someone in perfect health, and I hope you're able to see the ethical problems with that.
Cost-effectiveness shouldn't be ignored, but we need to recognize the thin ethical line we're treading on and how easily it is to slip into dangerously immoral mentalities.
Ryan Hutton how do you objectively judge a person's value though? Is a nurse worth more than a physio? Is a McDonalds worker worth more or less than a Walmart employee? Is an artist worth more or less than a bin man? Is someone who is currently unemployed worth less than a long term unemployed person who currently has a job? Who judges what is "useful" to society? Why does someone have to conform to what society wants them to be just to survive?
If you start not treating convicts too, you're getting into the realms of unjustified death penalty. What if the felon is falsely imprisoned? (Not uncommon). What if the crime is trivial? Do they deserve less of a shot at life? What if it's a crime that shouldn't really be a crime in the first place? (Laws change all the time) If you're american (or from numerous other countries where the same is true) what about the way the judicial system unfairly targets minorities? You're stumbling into the realm of accidental ethnic cleansing.
Selective treatment throws up all sorts of awkward questions that have no clear answers.
***** I'm not saying don't treat convicts at all. I'm saying don't be willing to spend as much on them. They won't all drop dead from that at the age of 50.
You judge someone's value based on their societal utility. This is largely shown by their wage however many jobs are underpaid because they are enjoyable and "fun" to do in certain ways to certain people - policing and teaching are fine examples of such and so those people would have to be weighted slightly higher than their wage would suggest. Jobs like train drivers are often slightly over-valued because even though it doesn't have gigantic utility considering how easy it is to do compared to other jobs it is boring as hell and so few want to do it.
Of course then you have to get into the whole valuing a person's future possible utility and frankly it would get too complex to be practical - monitoring their education, their other health needs be it physical or mental, their age and so on.
I don't think the fact that people are criminals itself is reason to be less willing to spend lots of $$$ on their health. So the thing about "what if laws change" is irrelevant. The reason why I would be less willing to spend money on their health is because they have a reduced likely future utility because of their criminal record which means they are more likely than a normal person to commit more crime and also will struggle with getting many different jobs.
It's not that a treatment isn't worth the money; it's that the treatment isn't worth NOT spending that money on something else.
How does the NHS justify covering IVF?
Even in the USA we can't afford to heat film sets enough to not require a coat.
Love these episodes, nice one :D
If only there weren't some federal law requiring us to buy a specific kind of health insurance, people could feel free to purchase coverage that only covered specific levels of QALY.
Good video.
Really interesting
I guess that's another reason the US pay more but get average results overall compared to some other countries.
Everyone's risk of death due to cancer would decrease if the government paid for monthly screenings of literally everyone for cancer?
Do the people who have issues with this video believe we should do that then?
Hopefully your answer is: "No, that would be ridiculously expensive and we can't afford it and even if we could we should be spending that money more efficiently on other healthcare services."
Quality-adjusted lightyears :o
Excellent!
It sucks that we have to talk about cost effectiveness in life or death situations. It really does. Nobody likes that! It's called "limited ressources" or "reality", whichever you prefer.
We have to set a price limit somewhere. Anyone denying that is being undeniably irrational. Think a drug that costs 1 billion $ for 1 extra day. As soon as you agree that this drug should NOT be covered then you agree that we should be talking about cost effectiveness.
$10,000,000/QALY is pretty fucking great if you force your neighbor at the point of a gun to pay for it and you have absolutely no intentions of paying for it (aka Obamacare).
I wonder if Healthcare Triage will have the balls to dissect every one of the 2000 page Obamacare bill and tell us how fucking awesome it is?
Oh god guys, did you see that? Cholesterol is next.
(Yesssss)
Wait what. What do you mean Americans dont take cost effectiveness into account?? What the hell. that sounds positively evil to me??? So what you just...guess??? what about resource allocation?? HOW IS THAT OK AT ALL?
i dont understand how cost effectiveness isnt considered??? cost effectiveness and resource allocation is a really important part of public health???? im so confused. what. is america even real
and here I thought a life was worth 35 shekels.
ballz
"I will apply, for the benefit of the sick, all measures which are required..." - HIPPOCRATIC OATH
shame on you for weighing money against health.
Think about it this way.
If we spend the money on one person for something that doesn't work, many more would have to go without. It's like spending a million dollars on a crumb to feed one person instead of using that money to buy whole food for everyone. Therefore, by not considering money, we're hurting more people. I know your appeal is very emotional, but that's all it is. Emotion.
Let me put it this way. If you and 999 other people were starving to death, and you had a finite amount of money, would you rather blow it all on a grain of rice to make one person feel better, but not helped at all, or would you rather save 999 people instead?
Diana Peña you assume that there is a limited amount of healthcare to go around, which is not the case. Also, you assume that i'm advocating crumbs, instead of measurable benefits to patients.
furthermore, you seem to not fully understand the separation between a physician and an insurance company. a physician should, as the oath states, always fight to apply all measures which are required for the benefit of the sick *not* "apply all measures that are required for the benefit of this sick unless you think it's too expensive." the insurance company took no such oath so they can make such a decision. A physician who advocates cost effectiveness in the absence of shortages is a disgrace.
there was nothing emotional about my statement. he did take that oath, he is breaking it by advocating cost effectiveness, and it is a shame.
your appeal assumes a lot and is very inaccurate, but that's all it is. assumption and inaccuracy.
***** that is not what that quote means.
The original Hippocratic oath also prohibits abortion, so I don't know how much doctors stick to that oath anymore. plus abortion results in probably about -70ish QALYs.
I don't like this way of looking at healthcare. I know they have to make money and they have to be smart with their money but putting a price on someone's life just seems wrong to me. If someone wants a treatment to save their life and they are 90 years old then I say they should have their autonomous decision and receive that treatment. You can't put a price on how many years a person has left and having money decide whether someone is going to live or die or in other words who is more qualified to live is just sickening to me. Again I understand that there is a limited amount of resources such as money but it is so sad that this is what our lives can potentially come down to.
This video has not aged well in our current political climate. Cost effectiveness is important, but also incredibly tone def to discuss in our current dilemma with CHIP defunded and medicaid on the chopping block. I have always appreciated your partisan tone, but discussing health care cost effectiveness is disturbing, and quite frankly infuriating, when we humor the $4,000 "price" for a month of prescription medication as "fair" and the system that denied it to her, including women's suffrage, as "fair". Neither was fair. Sometimes being called naive is unfair, but when people are dying and we're told to learn from it cheerfully... No sir, we should protest every moment of unfairness we can possibly perceive because most people cannot see how their lives have been toyed with by cruel people, indifferent to our suffering with more wealth and power than you or I could imagine. Don't facilitate their greed or the deaths of poor people even for a moment. NOT even for an important topic like cost effectiveness.
I feel like the amount of money and number of yours left to live should not determine if a person can receive a treatment. Life is greater than any amount of money there is to offer. If some one is elderly and wants a treatment to save them, they should be able to receive it no matter what.
+Deli Cee This is the sort of crap the industry wants you to think so they can squeeze every last penny out of you! By trying to make it seem like a choice between the materialistic option (keeping your money) or the nice, healthy, moral option (giving up money, and thus a more material life, for a healthy life for you and your loved ones), the healthcare industry is ironically just brainwashing you so you give them all your money for limited results. This isn't some crazy conspiracy theory, I say this as a chemistry student who may well end up making/developing drugs in the EU. I just find it disgusting how in the US they brainwash you, so effectively the customer ends up ripping themselves off because they think that's the only way they can do it! It's a seriously twisted situation when you think about it.
For the future, please, please pronounce its oreGUN, not oreGON. it's a not a big thing...its just annoying.