The mantras in health care today go something like this:
- The cost of healthcare is growing fast and is not sustainable.
- Doctors are responsible for this dilemma because they are paid and incentivized for doing more technical procedures, giving more medicine, and ordering more tests, which too often incur unnecessary costs.
- Patients, especially those with advanced solid cancers, and their families are responsible because they have unreasonable expectations for success.
- Pharmaceutical companies are responsible because they charge exorbitantly for new agents, some of which provide no benefit or marginal benefit.
- Patient advocates are responsible because they promote more therapy.
- Congress is responsible because it doesn't have the will to face this issue except with partisan demagoguery (“death panels”) to frighten people and stifle the search for and implementation of science-based cost reductions.
- President Obama is responsible because his health reform plan adds more patients to the insured ranks.
One definition of mantra is, “a sacred verbal formula repeated in incantation, such as a magic spell, containing mystical potentialities.” That is what the verbal traffic about health care sounds like to me today.
It is as if pointing the finger and shouting will somehow: (a) fix the problem; (b) put the blame on someone else, thus absolving the finger-pointer of any responsibility; or (c) add to the shouting chaos so that no change will take place, at least in that aspect involving the finger-pointer directly.
One also may look at the op-ed pages of the New England Journal of Medicine each week and reliably find another article or two by economists or policy wonks that contain The Solution(s) to the problem. That solutions may contradict one other is a tribute to the Journal editors' lack of bias, but it doesn't help one understand what can be done practically to reduce costs without sacrificing the quality of care while reducing the quantity of care.
But the 26 May 2011 issue of the Journal has a “Sounding Board” piece that I do understand: “Bending the Cost Curve in Cancer Care,” by Dr. Thomas Smith, an oncologist, and Dr. Bruce Hillner, a health services researcher. The authors offer recommendations for lowering the cost of cancer care that are feasible, practical, specific, and humane. To be sure, the recommendations would be difficult to carry out because of those who simply chant the mantras or see the issue only in political terms or personal financial terms.
The authors offer 10 recommendations—five deal with changes in oncologists' behavior and five with changes in attitudes and practice more generally. I can provide only a brief summary here, so read the article for the detailed supporting evidence and rationale (http://healthpolicyandreform.nejm.org/?p=14541)
Recommendations for Oncologists
Recommendations for oncologists from the authors (“Unless otherwise stated, our recommendations are restricted to the care of patients with incurable solid tumors and not those with curable cancers”):
- Target [restrict] surveillance testing or imaging to situations in which a benefit has been shown.
- Limit second-line and third-line treatment for metastatic cancer to sequential monotherapies for most solid tumors.
- Limit chemotherapy to patients with good performance status, with an exception for highly responsive disease.
- Replace the use of white-cell stimulating factors with a reduction in the chemotherapy dose in metastatic solid cancers.
- For patients who are not responding to three consecutive regimens, limit further chemotherapy to clinical trials.
Recommendations for Changing Attitudes & Practice:
- Oncologists need to recognize that the costs of care are driven by what we do and what we do not do.
- Both doctors and patients need to have more realistic expectations.
- Realign compensation to value cognitive services, rather than chemotherapy, more highly.
- Better integrate palliative care into usual oncology care (concurrent care).
- The need for cost-effectiveness analysis and for some limits on care must be accepted.
Sounds good, but does this have a chance of going somewhere? After all, these measures are not new and not very radical. Each recommendation has been raised in some form at meetings, in practices, and in publications. So why might it be timely and how would it be implemented?
I feel the same about this as I did when my colleagues and I started the Quality Oncology Practice Initiative (QOPI) through ASCO. Ten years ago one could see the push for quality measures growing after several reports from the Institute of Medicine decried the uneven and sometimes poor quality of cancer care and the lack of efforts to measure quality.
We had two firm convictions from the start of QOPI that also apply to the cost/care conundrum today. First, we oncologists had to take the lead in this activity or risk government or industry imposing some form of “quality” system on us. That has proved to be the right decision, and both government and industry have shown respect for the QOPI effort. QOPI is a leader in developing a system for addressing the quality of cancer care.
Second, since it seems inevitable that the cost of cancer care must decline or at least stop climbing, oncologists are the best advocates for patients and in the best position to know what is essential and what is not in cancer care since they have the experience and prompt, routine access to scientific publications that address these issues.
It is my view, therefore, that oncologists should take the lead in building a structure and a plan for controlling the cost of cancer care. It won't be easy and there will be many naysayers among us. But as was true for QOPI, we have a responsibility for shaping a system of high-quality cancer care that is humane, scientifically based when possible, and free of the wasteful and excessively costly use of resources, both human and financial.
If we don't do it, someone will impose a system on our patients and us. And there is a good chance that neither would like the result.