Cancer care has emerged as a prime target in efforts to contain health care costs.
Health policy makers have painted a bull’s-eye on oncology. Cancer therapy costs are skyrocketing, and the care itself is sometimes seen as fragmented and unsupported by persuasive evidence of effectiveness.
Moreover, cost hasn’t typically been a consideration for American oncologists. The prevailing ethos has been that they have a duty to offer a patient any possible treatment yielding a net benefit, regardless of the cost to society.
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Cost is not usually a consideration for American oncologists, but health policy makers have decided that spending on cancer care needs to be controlled.
That stance is no longer tenable, experts said in interviews and presentations at the recent San Antonio Breast Cancer Symposium.
"The growth in health care spending is unsustainable. Like it or not, efforts to control costs will increase. The question isn’t ‘Should cost be a consideration in the management of cancer?’ but rather ‘How will cost decisions be made and who will be responsible?’ " said Dr. Michael J. Hassett, a medical oncologist at the Dana-Farber Cancer Institute and Harvard Medical School, Boston.
Dr. Thomas J. Smith, the Harry J. Duffey Family Professor of Palliative Care at Johns Hopkins University, Baltimore, concurred.
"I’ve just spent the past couple of days talking to major insurers about the new Medicare/Medicaid innovations program, and everyone says oncology is a major target," said Dr. Smith, director of palliative care at Johns Hopkins Medicine. "It’s 15%-25% of their insurance costs. And there are demonstration projects showing that episode-based payment and salaried physicians work just as well and cost less."
The Association of American Medical Colleges plans to make "cost-conscious use of society’s resources" the next scientific competency required of medical school graduates, added Dr. Smith. "So we’re going to have to figure this out and teach it to the next generation, even if we ourselves didn’t get it right."
A defining experience for Dr. Eric P. Winer came when he and other international experts met in Portugal to draw up consensus guidelines on the treatment of advanced breast cancer.
"It was a surprising moment that seems to keep coming back to me over and over again: Many of our European colleagues were quite open in saying that newer drugs that might lead to a fairly modest survival advantage would probably not be used in their countries if the drugs were costly," recalled Dr. Winer, director of the breast oncology center at Dana-Farber and a professor of medicine at Harvard.
"That’s very different from the approach taken in the [United States] until now, although I think we’re really looking to make changes here," he said. "My own view is, if we don’t take control of this as the people who are providing care, then we will lose all control."
Yet if clinicians are to assume responsibility for considering costs in making cancer treatment decisions, they will have to traverse an ethical mine field, given their multiple potentially conflicting responsibilities as patient advocates, business owners, and citizen-taxpayers, cautioned Dr. Hassett.
Money and Outcomes Don’t Match
In 2009, nearly 18% of the U.S. gross domestic product was spent on health care. Analysts at the National Cancer Institute estimate that direct medical spending on cancer care in the U.S. amounted to $124.5 billion in 2010, with breast cancer care – accounting for $16.5 billion, or 13% of the total – leading the way. By 2020, just 8 years from now, they project that direct medical spending for cancer care will approach $158 billion annually, with breast cancer accounting for up to $25 billion of that figure (Cancer Epidemiol. Biomarkers Prev. 2011;20:2006-14).
How is that money being spent? A separate study concluded that total Medicare fee-for-service spending for breast cancer care during the initial year after diagnosis amounted to $1.06 billion in 2002. Surgery accounted for 25% of that payout, followed by chemotherapy at 15%, radiation therapy at 11%, and other inpatient care at 18% (J. Natl. Cancer Inst. 2008;100:888-97).
Unfortunately, all that spending isn’t buying better outcomes. By a variety of yardsticks, including 5-year overall survival and potential years of life lost due to malignancy, Americans fare no better and in some cases do worse than citizens of countries spending far less per capita on health care, said Dr. Hassett.
In a soon-to-be-published study, he and his coinvestigators analyzed total per-patient expenditures for all Medicare Part A and Part B services for breast cancer during the year following diagnosis of the malignancy in more than 15,000 women aged 65-70 years. Patients in the lowest quintile, with a median 1-year spending of $17,315, had a 5-year overall survival of 88%, identical to that in women in the highest spending quintile, at $26,808. Both quintiles had an identical 81% rate of adherence to 27 National Comprehensive Cancer Network guideline-based quality measures.