It's the medical oncologists' conundrum: new cancer medications can bring hope and clinical benefit but also exorbitant costs. Will it be worth it? And, to what extent should patients' pocketbook considerations be a factor in prescribing decisions? These are the questions that unavoidably place these physicians, who are trained to consider the clinical -- not financial -- implications of their decisions, in the middle of an economic predicament.
It's a dilemma not peculiar to cancer, but perhaps in no other disease are the stakes presented as frequently and as starkly. Out-of-pocket spending for cancer patients has increased sharply in recent years, especially for low-income individuals. Studies report that patients increasingly forgo expensive therapies or discontinue treatments, because they do not want to burden their families with debt.
In a recent national survey of oncologists, I, along with my colleagues at Tufts Medical Center and the University of Michigan, found most oncologists were very aware of these realities. For instance, eighty-four percent report that their impressions of patient out-of-pocket costs influence their prescribing decisions. More than 70 percent agreed that "over the next five years, costs of new cancer drugs will play a more significant role in my decisions regarding which cancer treatments to recommend for my patients."
On the other hand, most oncologists do not seem to talk regularly to their patients about costs. In our survey, only 43 percent stated that they always or frequently discuss cancer treatment costs with their patients, while 37 percent say they occasionally do and 20 percent say rarely or never.
This discrepancy between concern about costs and lack of communication seems to reflect physicians' discomfort with the subject and perhaps an absence of accurate knowledge about drug costs and insurance coverage. Other studies report that physicians say they do not have sufficient time for such discussions and do not have solutions to offer patients. For their part, patients mention their own awkwardness with the topic, and concerns about the impact of discussions on quality of care.
What to do? One place to start is with better information for physicians and patients on the benefits, risks and costs of cancer care. Notably, 79 percent of survey respondents favored more government research on the comparative effectiveness of cancer drugs. Some efforts have begun in this regard, including the recent establishment of the Patient-Centered Outcomes Research Institute to conduct such studies. In terms of education, patient advocacy organizations and oncologists' professional societies have been developing strategies for physicians and patients to communicate about costs and preferences.
Information and education alone will not be enough, however. There is also an urgent need for broader payment reforms that will change the manner in which drugs and physician services are reimbursed. In recent years, Congress has begun this process by altering the way Medicare pays physicians for chemotherapy drugs in an attempt to mitigate incentives for physicians to provide aggressive and costly treatments. Medicare has experimented with "coverage with evidence development" policies, requiring patients to participate in clinical trials or registries to help ensure that expensive drugs are delivered only to appropriate patients.
Other strategies are needed including realigning physician compensation to value cognitive services, and implementing expanded prospective payment systems or global capitation arrangements. Again, recent legislation has nudged Medicare in this direction, with bundled payments for the care of patients with end-stage renal disease and pilot programs for accountable care organizations, in which networks of physicians and hospitals share responsibility and potentially assume financial risk for providing care.
Finally, as Tom Smith and Bruce Hillner pointed out in recently in the New England Journal of Medicine, both doctors and patients need to have more realistic expectations. This means limiting diagnostics and therapies to ones with the strongest evidence, targeting treatments to patients with better prognoses, and better integrating palliative care into oncology practice.
It is difficult to mix economics and cancer care but it is unavoidable. The real question is how explicit we are in confronting the challenges involved.
Peter J. Neumann, Sc.D., a health economist, is the director of the Center for the Evaluation of Value and Risk in Health at the Institute for Clinical Research and Health Policy Studies at Tufts Medical Center, and a professor of medicine at Tufts University School of Medicine.