Ramsey's Rx for medicine: Optimize finite resources

When Dr. Scott Ramsey embarked on a career combining his dual loves of medicine and economics, he quickly added "thick skin" to his list of job requirements. As an advocate for cost containment and optimal treatment, he's found truth in the adage, "what's popular isn't always right, and what's right isn't always popular." His dogged pursuit of evidence-based medicine has won him many fans, but a few critics, too.

Treatment dilemma

Ramsey's work highlights one of the most disputed issues in medicine today. If a treatment helps people, should governments and private insurers pay for it without question? Or should they first measure the benefit against the cost, and only pay if the cost-benefit ratio exceeds some preset standard?

The United States generally follows the first course. Even the most cost-conscious insurers say they'll pay the price if a drug works and there aren't other options. Most other countries unapologetically adopt the second course. If a drug or type of surgery costs a lot and helps only a little, they say no.

Ramsey points out that there is not a bottomless pit of resources. The world reached the point a while ago where there is far more medical intervention available than any health-care system can afford.

"First, I want patients to get treatments that work. And if there are treatments that work equally well, I want them to get the most cost-effective treatment," said Ramsey, part of the Public Health Sciences Division faculty since 2001. "Cancer is so costly that I don't think it's in our interest to spend lots of money on things that don't offer a lot of value to patients. Unfortunately, much of what we do is very, very expensive and offers people very little, either in terms of survival or quality of life."

"I think in any profession, including oncology, we have to be mindful of our resources and use them well. If we use them poorly, waste money or spend money inefficiently, then someone else is going to make those changes for us because there just isn't enough money to go around. We need to be wise stewards of our resources."

Ramsey's research focuses on economic evaluations in cancer. He has published widely on patterns of care, costs and cost-effectiveness of treatments for lung, colorectal and prostate cancer. His current studies — ;funded by the National Cancer Institute, National Human Genome Research Institute, Centers for Disease Control and Prevention, and several pharmaceutical manufacturers — ;include a project to develop a genetic-screening policy model for colorectal cancer, a multicenter study of decision making for men with newly diagnosed prostate cancer, and studies of cancer screening, incidence, treatment and outcomes for Native Americans diagnosed with cancer.

Guiding the decision makers

He also works with health insurers throughout the United States, including Medicare, to help them decide what procedures and medication to cover or not cover. Ramsey has been involved in drafting guidelines to help the decision makers follow a more rational, systematic process.

Despite wanting what's best for patients, Ramsey endures his share of jabs. "Economics has always been viewed as the black sheep in the medical community," he said. "Part of the reason people attack me is that they have an economic interest in promoting a new technology or drug. I like being the independent assessor. Over the years, my skin has thickened."

Along with investigators at the University of Washington, Ramsey co-directs the NCI-funded Biobehavioral Cancer Prevention and Control Training Program through the UW Department of Health Services. The program is designed to train the next generation of cancer-outcomes researchers, offering those with backgrounds in epidemiology a chance to learn more about the clinical side of cancer. It also attracts cancer biologists who want to study outcomes research.

"We're trying to train interdisciplinary researchers to take the science and move it toward application," Ramsey said, noting that NCI considers it a model program. He also teaches several UW classes for the Schools of Medicine and Pharmacy, as well as at the Institute for Public Health Genetics. In addition, he sees patients one day each week at the UW General Internal Medicine Center.

Ramsey's road to economics

The pursuit of economics came as a means to escape undergraduate misery for Ramsey. Initially, he was a pre-med major at the University of Iowa, but he disliked the other pre-med students so much ("I found them awful. They were so competitive and would cheat on tests and sabotage other people's lab results.") that he fled to an economics course. He saw economics as a fascinating look at human behavior, so he switched majors. While in medical school, Ramsey heard of a new doctoral program in health economics at the Wharton School of the University of Pennsylvania. For the next three years, he pursued his doctorate at Wharton and then finished medical school.

"I was always trying to find a way to blend medicine and economics. I felt that each one informed the other in ways that, to me, were important if I was going to write, talk and research in this field," he said. "When I tried to ask deeper questions in medical school about how they knew X causes Y or this treatment works better than that one, I couldn't find information supporting it. It made me want to do research and be a part of improving the evidence."

Ramsey was a trailblazer in applying the bottom-line accountability of the business world to health-care choices. "When I entered this field, you could count on one hand the number of health economists who were also physicians. It might be two hands now — ;still not too many," he said. "I was very ahead of the curve." Ramsey feels like the Center is an ideal place to pursue his research. "I'm a bit of an oddball researcher here, but I've found support throughout the Center and people eager to look at their particular cancer focus and research through a policy or economics lens."

Dr. John Potter is one of many collaborators who appreciates Ramsey's business-medicine perspective. "Scott is a great colleague," said Potter, head of the Public Health Sciences Division. "We have worked together on a several projects, including helping with the design and implementation of the Seattle Cancer Care Alliance Prevention Clinic, where Scott's insights and patience have been of benefit to all of us." The Prevention Clinic opens in the fall. The collaborative effort is aimed at healthy people who want to learn about and lower their cancer risk. "It's a whole new concept in cancer prevention," said Ramsey, who will direct the clinic. "Prevention efforts have very good value, but are significantly underused. I would like to see that fixed."

Though Ramsey still has decades of work in front of him, he's proud of what he's accomplished so far. "The biggest influence I've had is that economics is now part of the dialogue in almost any clinical trial," he said. "And when it comes to the point of covering new therapies, economics is not a taboo subject. It's being openly weighed alongside the clinical evidence."

"We haven't gotten to the point — ;unlike most of the rest of the world — ;where we say we're not going to cover things that cost a whole lot of money and don't do very much. We have this illusion that there are infinite resources, but that illusion is being tested sorely right now as costs go up and we're up to 50 million people uninsured. Rather than cutting more people out of insurance, I would rather cut out things that don't work, and use that money to insure people. Seems like a win-win to me."