The Gray Tsunami

You may recall recent findings that the rate of dementia among people 65 and older has been falling in England and Wales, and this is likely true here as well. It's basically because people are generally healthier. But . . .

It's very strange how the general reaction seems to have been, "Oh well then, what have we been so worried about?" News that isn't quite as bad as you thought it was going to be is still bad news. And the fact is that the prevalence of dementia still rises with age, and we're still going to have a lot more people living with dementia in coming years. The estimate here of tripling by 2050 might be too high, but 2 1/2 times as many is still a whole lot.

Now the IOM raises the alarm about cancer, another disease that is strongly associated with increasing age and which costs a whole hell of a lot of money to treat. Here's a good example of why medical advances can drive medical costs: there aren't any effective treatments for dementia, so it's actually relatively cheap. Many people do ultimately need custodial care and that can bankrupt families and strains Medicaid budgets, but Medicare is going to have to pay for all this cancer care and new therapies can cost $100,000 and up. Even though the benefit is generally small, our laws and our cultural consensus say that we still have to pay for them.

IOM also argues that advances in the field are so rapid that many physicians and treatment centers aren't keeping up; and that we'll have a growing shortage of relevant experts. It's hard to predict how this will play out. Advances in what are called medical informatics may make it easier for providers to select the right treatment protocols and deliver the latest, proven technologies. Basically, they won't have to know everything, the computer will tell them. (They will have to ask it the right questions.) Treatments that are really curative may end up saving some money in the long run, or cheaper treatments may emerge, but I'm not going to bet on that.

We can save money by all the means I talk about here -- not overdiagnosing and overtreating, not using useless treatments and tests, not overpaying for specialty care. At least we can in principle, it's proving to be very difficult politically because all that waste is somebody's income. But even if we manage to do that, medical costs will continue to increase. We're a wealthy society, we can afford it, but it means young and healthy people will have to pay for the care of old and sick people. That's a granite hard fact of life. Are we prepared to do it?

Update: And right on cue, This lands in my in-box. (I swear, it was after I put up this post.)

PLAINSBORO, N.J. – Promising targeted therapies and immunotherapies for melanoma, used in combinations so advanced they have outpaced the nation’s regulators, offer hope of survival to patients suffering from a cancer once seen as a “hopeless” malignancy, according to experts convened by The American Journal of Managed Care. A. Mark Fendrick, MD, co-editor-in-chief of AJMC, led the discussion with the following experts:

• Jeffrey Weber, MD, PhD, senior member, H. Lee Moffitt Cancer Center and director, Donald A. Adam Comprehensive Melanoma Research Center.
• Antoni Ribas, MD, PhD, Jonsson Comprehensive Cancer Center, UCLA.  
• Jennifer Malin, MD, PhD, manager and medical director of oncology, WellPoint.

 “Melanoma has gone from being regarded by many oncologists in the community as an impossible-to-treat and hopeless malignancy to a disease that one might argue is the poster child for new targeted and immunologic therapies,” Dr. Weber said.
However, these drug combinations are not cheap, and the panelists warned that there is only so much that cancer patients, their employers and those who fund government health plans will be willing to pay. Already, Dr. Ribas warned, some melanoma patients lack access to cutting edge drugs like ipilimumab, depending on where they seek treatment and whether they have appropriate insurance coverage.