Although many oncologists are reluctant to discuss treatment costs with their patients, rising costs are weighing on their minds and influencing their clinical decision-making, according to a national survey of oncologists.
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Only 43% of survey respondents always or frequently discuss treatment costs with their patients, but 84% said that their patients' out-of-pocket spending influenced the oncologists' treatment recommendations.
Results of the survey, conducted by researchers at Tufts Medical Center and University of Michigan, were reported in the January issue of Health Affairs.
“It's a very sensitive area and fraught with challenges and complications, but the data show that oncologists are thinking about costs, considering costs, and struggling with costs,” said Peter J. Neumann, ScD, Director of the Tufts Center for the Evaluation of Value and Risk in Health.
Dr. Neumann and his colleagues analyzed responses from 787 oncologists who participated in a written survey conducted in mid-2008.
The responsibility to consider costs associated with their treatment recommendations is a relatively new role for oncologists, and one that may eventually thrust them into a national conversation about the appropriate relationship between cost and health care services. While cancer treatment accounts for a small fraction of America's total health care spending, the rapidly rising cost of cancer care poses a dilemma for many patients and their families. Dr. Neumann and his coauthors cite research that shows that out-of-pocket spending for low-income cancer patients amounts to 27% of their annual income.
Neal J. Meropol, MD, the Dr. Lester E. Coleman, Jr. Professor of Cancer Research and Therapeutics and Section Chief for Medical Oncology at University Hospitals Case Medical Center and Case Western Reserve University, said he believes that cancer care shines a spotlight on the way in which American society implicitly rations medical care by patients' health insurance status and other financial resources.
“Currently we have a big problem in our country regarding the high number of uninsured and underinsured who have cancers diagnosed at later stages and die more frequently from cancer. We need to ask ourselves whether we should move from a situation of implicit and often unfair resource allocation decisions to one in which we are more explicit about these decisions regarding the allocation of health care resources, such that disparities in care and outcomes are minimized.”
ASCO Tackles the Issue
Oncologists are being encouraged to have explicit conversations with their patients about the cost of treatment options, and the American Society of Clinical Oncology's Cost of Cancer Care Task Force is taking a lead.
“ASCO feels that it is a doctor's responsibility to help patients understand this particular dimension of their illness,” said the Task Force's Chair, Lowell E. Schnipper, MD, the Theodore and Evelyn Berenson Professor of Medicine at Harvard Medical School and Chief of the Hematology/ Oncology Division at Beth Israel Deaconess Medical Center.
Patient-physician discussions regarding the cost of care are an important component of high-quality care,” while oncologists do need education and support tools to have these discussions, noted ASCO's resulting guidance statement, published last year in the Journal of Clinical Oncology (2009;27:3868–3875) with Dr. Meropol as the lead author.
To that end, ASCO is developing a curriculum to educate doctors about how to discuss treatment costs with their patients and has published a guide targeted to patients, encouraging them to discuss costs with their physicians (OT, 6/25/09).
Cost-Effectiveness & Comparisons
Of course the issue facing an individual patient is not just the cost of a given treatment, but the cost-effectiveness of each option and a comparison among the various options. Dr. Neumann's survey found that physicians are eager to have more information to help with treatment decision-making.
A full 80% of the oncologists responding to the survey favored more use of cost-effectiveness data in coverage and payment decisions for cancer drugs. Despite that, only 42% of respondents said they feel well prepared to interpret and use information about cost-effectiveness.
“Cost-effectiveness is not part of the practical day-to-day process that is incorporated into decision-making. Many of us think that is a needed change,” Dr. Schnipper said. “We think there needs to be some comparison between new therapies and existing therapies but there also needs to be some judgment made as to how much better [a given treatment is] and at what cost and at what toxicity.”
How Much Is Too Much?
The new study shows that there is no consensus about how the balance between effectiveness and cost should be arrived at, let alone the consideration of side effects. When asked “What do you think is a reasonable definition of ‘good value for money’ or cost-effectiveness per life-year gained?,” 49% of respondents chose the range between $50,001 and $100,000 per life year; 21%, though, said $50,000 or less, while 30% said more than $100,000.
The findings of the new study contrast somewhat with those of a widely cited earlier paper that Dr. Neumann coauthored with lead author Eric Nadler, MD, and others (The Oncologist 2006:11:90-95) Pressed to answer a hypothetical question, 62% of academic oncologists responding to Dr. Nadler's survey said they believed that gaining two to four additional months of life justified the use of a hypothetical treatment that cost $70,000 a year more than the standard of care. Dr. Nadler and his colleagues extrapolated the responses to find that the median implied cost-effectiveness ratio was $280,000 per quality-adjusted-life-year.
Dr. Neumann's more recent study asked oncologists in a more direct way to quantify cost-effectiveness and elicited a much lower dollar value.
“Maybe it's not terribly surprising, but I think it's notable,” Dr. Neumann said. He points out that, because the questions were different in the two studies, the findings are not necessarily comparable.
Regardless of how oncologists value cost-effectiveness, Dr. Meropol believes setting a hard threshold for cost-effectiveness of cancer care may not be appropriate: “Cancer care is unique in that a simple coverage threshold for value may not be as appropriate as in other realms,” he said. “There may be societal value in treating cancer patients with rare and life-threatening diseases with therapies that otherwise might be considered to be too costly.”
Recognizing that Health Care Resources Are Finite
That said, Dr. Meropol urges society to recognize that health care resources are finite and should be allocated thoughtfully. How that happens is unclear. When Dr. Neumann asked oncologists who should determine whether a drug provides good value for money, 60% of respondents said physicians and 57% said nonprofit organizations. The choices were not mutually exclusive: 37% of oncologists said patients should make the determination, followed by government (21%) and insurance companies (6%)
“Doctors, patients, payers and government officials may have widely disparate views about how resources should be allocated and if we are to move to a more consistent approach to health care resource allocation we need to find a way to obtain and integrate the input of all the stakeholders involved,” Dr. Meropol said.
Before that can happen, all stakeholders have to agree that the term “too costly” can apply to cancer care. Dr. Schnipper interprets that the ambivalence with which oncologists view discussing costs with their patients as reflective of the “can-do” attitude that both they and their patients want to embrace.
“The cultural ethos in the United States is that it's hard to believe that a disease can get the better of us with such great technologies available,” he said. “And there is often substantial resistance by patients, families, and their oncologists to acknowledge the inevitable in terms of the immediate life-threatening potential of cancer that has progressed through all available therapies. That's part of our culture, and it will change only over time and very, very gradually.”
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