THCB

How to Lower Cancer Care’s Costs

A year-and-a-half ago, Howard Brody of the University of Texas Medical Branch in Galveston wrote an opinion article in the New England Journal of Medicine calling on every medical specialty to develop ways of cutting the cost of care. Citing financial sacrifices that had been made by insurers, hospitals, drug and device companies in the then pending health care reform bill, Brody said physicians could do their part “if they were willing to practice more in accordance with evidence-based guidelines and to study more seriously the data on regional practice variations.”

Toward that end, he called on each specialty to come up with a list that “would consist of five diagnostic tests or treatments that are very commonly ordered by members of that specialty, that are among the most expensive services provided, and that have been shown by the currently available evidence not to provide any meaningful benefit to at least some major categories of patients for whom they are commonly ordered.”

In the NEJM last week, two oncology specialists — Thomas Smith and Bruce Hilner of Virginia Commonwealth University — took up the challenge. They created a “top five” list of common oncology practices, which, if limited to situations where they were truly clinically useful, would sharply lower the cost of cancer care. Their lead paragraph noted the need for taking these steps:

Annual direct costs for cancer care are projected to rise — from $104 billion in 2006 to over $173 billion in 2020 and beyond. This increase has been driven by a dramatic rise in both the cost of therapy and the extent of care. In the United States, the sales of anticancer drugs are now second only to those of drugs for heart disease, and 70% of these sales come from products introduced in the past 10 years. Most new molecules are priced at $5,000 per month or more, and in many cases the cost-effectiveness ratios far exceed commonly accepted thresholds. This trend is not sustainable.

Look closely at the second to last sentence of that paragraph: “In many cases the cost-effectiveness ratios far exceed commonly accepted thresholds.”  It’s worth noting that there are no commonly accepted thresholds for cost of care in the U.S. That’s not true in Great Britain, where the National Health Service, based on recommendations from the National Institute for Clinical Excellence, will refuse to pay for certain drugs when their costs exceed certain levels. But in the U.S., Medicare, which is the primary payer for most cancer care since cancer is primarily a disease of aging, is forbidden by law from taking cost into consideration. If the Food and Drug Administration has approved a specific approach, and the doctor prescribes it, Medicare will pay for it. If the oncologist tries an approach that is not specifically approved by the FDA — either as an “off label” use or combination of approved drugs — the Centers for Medicare and Medicaid Services will still pay for the treatments long as the approach is listed in clinical practice guidelines. And when it comes to most testing and imaging, most insurers including Medicare will pay for whatever the doctor orders, even though the medical literature is loaded with studies suggesting their lack of usefulness in many situations where commonly used.

That’s why oncologists themselves have to take this issue on. Here’s their top five list of new rules for controlling the cost of cancer care:

  1. Only use testing and imaging where “benefit has been shown”;
  2. Limit second-line and third-line treatments to metastatic cancer to sequential monotherapies for most solid tumors. “Patients will live just as long but will avoid toxic effects. . . Society will benefit from cost reductions associated with less chemotherapy, fewer supportive drugs, and fewer toxicity-associated hospitalizations”‘;
  3. Don’t give chemotherapy to people when their cancer has made them so weak that a positive response is highly unlikely;
  4. Lower chemo doses to eliminate the routine use of drugs that replace the white blood cells destroyed by toxic chemo drugs; and
  5. Stop treating patients if they haven’t responded to three different drug regimens — unless they are enrolled in a clinical trial actually testing the fourth regimen.

They also came up with a list of five changes in physician and patient attitudes that must take place to cut the cost of care, ranging from support for end-of-life counseling to more support for hospice and palliative care. “We understand that this will be extraordinarily difficult, since one person’s cost constraint is another person’s perceived lifesaving benefit and yet another’s income,” the two authors write. However, “there really is no other way. Our intention is to encourage other specialties to do the same and flatten the cost curve so that patients can continue to get the best new therapies.”

Now, here’s my top five list of how the editorial page of the Wall Street Journal will respond to this call for rationing based on science and common sense:

  1. It’s rationing that abrogates physician autonomy;
  2. It’s rationing that prevents individual choice in evaluating the trade-offs between benefits and risks;
  3. It’s rationing that denies very ill patients hope;
  4. It’s rationing that puts cost ahead of best practices; and
  5. Did I mention that it’s rationing?

And as far as end-of-life counseling is concerned, we’ve already heard right-wing politicians crying “death panels.”

I congratulate Smith and Hilner for taking on the Brody challenge. But there was one other issue I wish they had addressed. Why are cancer drugs of marginal efficacy so expensive? Why does a drug that extends life by a month or two cost $5,000 to $10,000 a month for the last year or two of a person’s life, thus adding up to a quarter million dollars to the cost of end-of-life care?

One could write a book about why there’s no economic justification for these sky-high prices (See this one, for instance). Last year, two Sloan Kettering researchers, writing in Health Affairs, proposed pricing new cancer drugs at the medical value they deliver — so-called reference pricing. I wrote about it here.

There’s a lot that oncologists can do to reduce the cost of care through eliminating unnecessary tests, images and treatments. But they should also begin raising their voices when they see drug companies charging an arm and a leg for products that they know, better than anyone else, really aren’t worth the money.

Merrill Goozner has been writing about economics and health care for many years. The former chief economics correspondent for the Chicago Tribune, Merrill has written for a long list of publications including the New York Times, The American Prospect, The Washington Post and Financial Times. You can read more pieces by him at GoozNews, where this post first appeared.

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Директ финанс самараe-like.rohotels santa barbaraRobin MonsonJohn Ballard Recent comment authors
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Директ финанс самара
Guest

искал в гугле Директ финанс самара, нашел ваш блог How to Lower Cancer Care's Costs | The Health Care Blog, спасибо!

e-like.ro
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hotels santa barbara
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Robin Monson
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Robin Monson

I agree witih Barry Carol’s remark May 30, 2011. For the most part, physicians are trained to heal, not to provide palliative care. By providing a complete explanation of the disease process, estimated life expectancy, side effects of treatment modalities and any benefits that may be achieved, patients may be in a better position to make a decision. In my experience, life expectancy is usually not discussed with the patient if the patient does not ask this question. I do have a problem with placing individual choices in the hands of physicians regarding options available. Where does the line get… Read more »

John Ballard
Guest

When our kids were growing up we called it “The Last Word” game. Whoever gets the last word wind.
“Did not.”
“Sure did!”
“Didn’t.”
“Did.”
“Didn’t.”
“Did.”
“Did not.”
“Did.”

You get the idea. Something like “Mama, he’s staring at me. Make him stop looking at me!”

Nate Ogden
Guest
Nate Ogden

“He will go off on a nasty rant”

“It’s clear that you also lack an understanding of basic trade principles.”

“My dear flaming Nate”

“like your understanding of, for instance, the health care system or poverty in the US, pinhead size.”

“he is such a rude flaming diehard”

Project much Mark?

“Nate is right even when he is wrong.”

Never heard back from you on how fungible oil is, is your new argument that every oil processor building refineries doesn’t know what they are talking about either?

John Ballard
Guest

Mm-hmm…
Modest, too.

Mark Spohr
Guest

Nate is right even when he is wrong. He will go off on a nasty rant and leave you confused about how to even start a response. It’s the perfect way to end a discussion. I try not to respond to him but he is such a rude flaming diehard that it is hard to not challenge his absurd statements. However, it always ends badly so best to avoid him if you can.

Nate Ogden
Guest
Nate Ogden

John, I probably shouldn’t give this secert away but if you promise not to tell anyone I’ll let you in on it; “he’s always right.” It’s not that I am always right, if I don’t know something I don’t go posting about it on the internet though. If I am going to comment about something I first know what I am talking about or I don’t say anything. That might give the allusion I am always right but it doesn’t address the countless things I have no clue about. If there are discussions about the correct treatment for this or… Read more »

John Ballard
Guest

Nate Ogden is amazing.
He has a reply for nearly every comment and he’s always right.
(Still looking, but I have yet to read an unqualified endorsement from him. Sadly nobody gets anything exactly right. )

Craig "Quack" Vickstrom, M.D.
Guest
Craig "Quack" Vickstrom, M.D.

This article has brought the real issue of health care to the fore: the recognition that the resources of even the USA are not infinite, and the argument over how to allocate these scarce resources.

We have the faction that argues vehemently against subsidizing our own people, but argues strenuously for subsidizing other people. Then we have the faction that argues for subsidizing our own people, but against (large-scale) subsidizing other people. I can only wonder how this is going to play out in the years to come.

Nate Ogden
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Nate Ogden

if your dishonest framing of the issue is any indication then very polarizing. “We have the faction that argues vehemently against subsidizing our own people” Who has said we should end all subsidies and assistance, no one is making this argument. They are arguing the extent to which we assist them and the fact we often ask or expect nothing in return. “Then we have the faction that argues for subsidizing our own people, but against (large-scale) subsidizing other people.” This is an accurate portrayal. I can wager which one you see yourself as, the second one with the nuanced… Read more »

Barry Carol
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Barry Carol

Mark – Thanks for that comment. I suspect that the oncologists who treated your friends were guilty primarily of offering false hope as opposed to a desire to make more money. To deal with the payment issue pushing oncologists toward more aggressive treatment rather than less, United is experimenting with a bundled payment approach. Oncologists can still treat more aggressively than the bundled payment calls for in certain cases if they think it’s appropriate, but they will only be reimbursed for their incremental cost and will not make any profit from the extra treatment. Some oncologists, as I understand it,… Read more »

Craig "Quack" Vickstrom, M.D.
Guest
Craig "Quack" Vickstrom, M.D.

“The mentality among patients that more care is always better care and more expensive care is better care needs to change as well.”

THAT mentality has to change everywhere, with everyone.

rbaer
Guest
rbaer

Not with everyone. As I mentioned above, there are patients who want to use drugs and surgery as little as possible, some because of general preferences, others explicitely due to cost considerations. However, docs are often in a bind, as patients and families sometimes become quite irritated when you suggest doing less (and when one says: test x would very unlikely change management, they counter: yes, but it is important to know). And, I would venture, 90% of practicing docs, myself included, will tell you that defensive medicine plays a role. Ideally, docs and patients would abide to the few… Read more »

Craig "Quack" Vickstrom, M.D.
Guest
Craig "Quack" Vickstrom, M.D.

True, true. I would say defensive medicine plays a BIG role, but that is own circumstance. YMMV.

Margalit Gur-Arie
Guest

Barry, “Or, do they say there’s nothing more we can do for you aside from comfort care, palliative care or hospice care?” I would suggest that the current practice, if oncologists are erring on the side of hope, may be for the financial benefit of certain stakeholders. The equally dishonest alternative above is for the financial benefit of a different set of stakeholders. Either way it’s solely about money and not about the patient as a person (I don’t want to use the term patient-centered since it rings hollow to me by now). I appreciate you not wanting to fund… Read more »

Barry Carol
Guest
Barry Carol

“and would you also agree Barry that if after all these steps the fully informed patient decides to “go for it”, we as a society will assume the costs?” Margalit – Not necessarily. I’ve said previously that I don’t think we should pay for expensive cancer drugs that cannot meet a reasonable QALY metric standard. If patients want to spend their own money for a non-covered drug, that, of course, is fine by me. The second issue is the age of the patient. If it’s a child or a relatively young adult, it’s easier to justify a full court press.… Read more »

Craig "Quack" Vickstrom, M.D.
Guest
Craig "Quack" Vickstrom, M.D.

Maybe we can talk about this as a society, after we dismantle our foreign military bases and bring all our troops home. Let our corporations hire their own private military to protect their overseas assets.

Margalit Gur-Arie
Guest

Brilliant!!

Nate Ogden
Guest
Nate Ogden

Next time 1 million poor africans are lined up for slaughter your ok with us just staying home Craig? Not all wars are for corporate interest, some of us take issue with dictators who kill hundreds of thousands of people, the same dictators the left tends to embrace and the NYT gushes over. See Sean Penns phonebook for examples

Craig "Quack" Vickstrom, M.D.
Guest
Craig "Quack" Vickstrom, M.D.

Of course I’m not OK with it. But the USA should be a republic, not an empire. We can certainly do our part and be good citizens of the world without building military bases in other countries. As for dictators and violators of human rights (many of whom our governments supports), the UN and the ICC are the proper venues for dealing with that. Also, all this unilateral global military intervention is expensive. Time to take care of our own people first.

Nate Ogden
Guest
Nate Ogden

“We can certainly do our part and be good citizens of the world without building military bases in other countries.” Great sound bite now lets look at reality, the same thing that tripped up Obama and all his promises. Without a base in the DMZ how would you propose keeping North Korea out of South Korea, if we hadn’t been there we would only have one Korea today and it would be communist. Our bases in Europe after WWII helped slow the spread of communism, something I am sure you are quit sad about. I wonder if your greater objection… Read more »

Nate Ogden
Guest
Nate Ogden

” all this unilateral global military intervention is expensive. Time to take care of our own people first.”

missed this, we already have the fatest poor, biggest houses, most rooms, most TVs, on and on, its time for Americans to take care of themselves.

Margalit Gur-Arie
Guest

Poverty is a relative term. “By necessaries I understand, not only the commodities which are indispensably necessary for the support of life, but whatever the custom of the country renders it indecent for creditable people, even of the lowest order, to be without. A linen shirt, for example, is, strictly speaking, not a necessary of life. … But in the present times, through the greater part of Europe, a creditable day-labourer would be ashamed to appear in public without a linen shirt … Custom, in the same manner, has rendered leather shoes a necessary of life in England. The poorest… Read more »

rbaer
Guest
rbaer

Nate wrote: “we already have the fatest poor, biggest houses, most rooms, most TVs, on and on, its time for Americans to take care of themselves” “biggest houses, most rooms” – did you ever notice that space is a cheap resource in the US, but scarce in densely populated Europe and Japan? “fattest” – rather a reflexion of US cultural and dietary factors. In developed nations, calory deprivation is not a problem, and calories galore do not compensate for a deficient diet. “most TVs” – the US is the only country where families put TVs in every room including the… Read more »

Nate Ogden
Guest
Nate Ogden

” If you think that a TV or two indicates material security, one has to question your priorities.” If you think our poor having to forgo a 7th TV for their bathroom so we can keep some troops overseas to prevent Rwandans from being massacred by the tens of thousands is unacceptable then we need to discuss your morality. We spend more than we should to subsidize our poor, far more. Much of that money is wasted and spent inefficiently so the results are poor but it is not a lack of spending. We also get very little back from… Read more »

rbaer
Guest
rbaer

You are fantasizing about the number of TVs and the number of “rooms” in poor peoples homes. You are fantasizing about welfare expenses, unless you mean medicare. You also seem to indicate that the US is doing to little in terms of military intervention … nothing was done by the US in Rwanda. What has been done by the US has to do with perceived geopolitical interests and resources, enough humanitarian crises have passed without intervention. Let me ask you, Nate, do you think that the military endeavors over the last decade has been well invested money? It’s a “health… Read more »

Nate Ogden
Guest
Nate Ogden

” the number of “rooms” in poor peoples homes.” I never gave a number how do you know I was fantasizing? Thats right you project everything anyways so what I was really thinking doesn’t matter becuase you will just make it up for me anyways to fit your argument. Just read an article about food stamps and how the cost is blowing up, was that a fantasy, did I imagine the numbers the USDA cited? I wish it was true, at that growth rate Liberals will be wanting to socialize food distribution by the end of the year. 14% on… Read more »

Margalit Gur-Arie
Guest

Saddam? You mean the guy that we supplied with weapons of all sorts while he was fighting Iran? Weapons which he used internally and externally
Funny how he became a menace to society when he started threatening our enlightened humanitarian friends in the Saudi peninsula, which just happens to be sitting on this huge barrel of oil…..

Nate Ogden
Guest
Nate Ogden

As a card carrying flaming liberal hopefully you can help me with this argument. I never understood what liberals meant/mean when they talk about Saddam’s oil and how we invaded for the oil etc. I have a pretty good understanding of the commodities market and the flow of oil between nations. For the life of me I can’t figure out what Saddam’s oil has to do with anything. It was barely measurable how much their oil contributed to our supplies. It wouldn’t effect us one way or the other if they pumped or didn’t pump. Now if Venesula or Canada… Read more »

Mark Spohr
Guest

My dear flaming Nate… you are short on facts again. Iraq has more oil than Kuwait, UAE, Libya, Nigeria, Venezuela, and Russia. Your “pretty good understanding of the oil market is, like your understanding of, for instance, the health care system or poverty in the US, pinhead size. We did arm Saddam (he was our BFF and Dick Cheney visited personally) and he ended up exterminating hundreds of thousands of his people and Iranians (as well as Kuwaitis). The US realized even before WWII that control of Middle East oil was essential to world domination and that is why we… Read more »

Nate Ogden
Guest
Nate Ogden

Hi Mark…….um can I make a suggestion? Please reread what I said then let me know if you would like me to maybe accept an apology or something. ” It was barely measurable how much their oil contributed to our supplies.” FYI Their = Iraq and our = America’s “Iraq has more oil than Kuwait, UAE, Libya, Nigeria, Venezuela, and Russia.” http://www.eia.gov/dnav/pet/pet_move_impcus_a2_nus_ep00_im0_mbbl_m.htm #1 Canada #2 Mexico #3 Saudia Arabia #4 Venesuela #14 Iraq What were you saying about my facts? The amounbt of Oil the US gets from Iraq is a rounding error.

Margalit Gur-Arie
Guest

Nate, Saddam’s move into Kuwait and the threat on Saudi Arabia would have destabilized the entire global oil supply. Not to mention that the paragons of human rights, and still our best friends ever, the Saudis. had a dog in that fight ….. so we obliged.
I’m not contending that we should have sat still and watched Kuwait burn and Saudi Arabia burn after that, and the UAE burn too, but let’s just not call it human rights and/or weapons of mass destruction and/or imaginary terrorists under rocks. Call it what it is.

Nate Ogden
Guest
Nate Ogden

“Nate, Saddam’s move into Kuwait and the threat on Saudi Arabia would have destabilized the entire global oil supply.” Inspite of liberal attempts to completly get rid of it 40% of our oil is domestic and another 30%? is from Canada. If Bush had got antsy and nuked the entire middle east this would not have been destabilized, I think the supply from Mexico would also have been pretty secure. Thats sort of the misnomer here, there is no global oil supply, for numerous reasons oil has some pretty specific flows. Its not like we could or would suddenly source… Read more »

Margalit Gur-Arie
Guest

There are terrorist camps all over the Middle East. Why not invade Syria, Libya, Iran or whatever? Besides, I thought this was about human rights, no? You can easily invade half the globe on account of human rights, but we don’t. Disturbing the global oil market would disturb global commerce and in turn American economy. You don’t have to actually buy oil from them to be severely affected. There was a good reason to initially turn on our former ally, Saddam, and kick him out of Kuwait. Unfortunately, we never finished what we started. There was no compelling reason for… Read more »

Mark Spohr
Guest

My dear Nate, It’s clear that you also lack an understanding of basic trade principles. Although not much Iraq oil reaches the US, oil is “fungible” (look it up if you don’t understand the meaning of the word). Even when the US imported little oil from the Middle East, we understood the strategic importance of the oil and needed to control it. Iraq reserves are #4 in the world and are vital to US control of world oil supply and that is why we went to war. If you believe that Iraq oil is not important to our control of… Read more »

Nate Ogden
Guest
Nate Ogden

“There are terrorist camps all over the Middle East. Why not invade ……, Libya,” I believe that is being done now no? You can’t fight them all at once. Are you saying terrorist should not be attacked? We should respect their right to be terrorist and let them attack us? Its not just in the ME, South America and more then enough state sponsors as well and we spend millions and even foots on the ground fighting them as well. ” oil is “fungible” ouch, sorry to make you look stupid again but no oil is not fungible. Different processing… Read more »

Nate Ogden
Guest
Nate Ogden

margalit some of marks responce jumped in the middle of yours, sorry

Mark Spohr
Guest

“do they say there’s nothing more we can do for you aside from comfort care, palliative care or hospice care?”

Sometimes the honest answer is this… “the best we can do for you is to make you comfortable at home since you have an incurable disease and our treatment will only make you miserable for the few remaining months of your life.”

I know three friends in the last year who would have had a much higher quality “end of life” if their oncologists had been honest with them.

services billing massachusetts
Guest

The financial costs of cancer care are a burden to people diagnosed with cancer, their families, and society as a whole. National cancer care expenditures have been steadily increasing in the United States. Cancer care accounted for an estimated $104.1 billion in medical care expenditures in the United States in 2006. In the near future, cancer costs may increase at a faster rate than overall medical expenditures.

Barry Carol
Guest
Barry Carol

From a patient’s perspective, I don’t think it’s too much to ask of oncologists to do the following: (1) Provide an honest assessment of the disease stage, estimated range of survival time including the mean and median, and treatment options, (2) Fully explain the likely side effects that come with each treatment option as well as the probable impact on quality of life so the patient fully understands what he/she is signing up for, (3) Be willing to work with palliative care and/or hospice specialists if that’s what the patient wants, (4) Don’t offer false hope and (5) Don’t view… Read more »

Margalit Gur-Arie
Guest

and would you also agree Barry that if after all these steps the fully informed patient decides to “go for it”, we as a society will assume the costs?