More About Balancing Business, Humanity, and Restraint in Cancer Care

I published a column in Kaiser Health News about the challenge of cost control in cancer care. KHN needed to cut one section for space, which notes that oncology has become an ecosystem of multi-billion-dollar public, private, and nonprofit ventures in pharmaceutical development, imaging, acute care, and more. This ecosystem draws upon and then reinforces broader cultural biases that promote overly aggressive approaches to diagnosis and care. I wanted to add some more discussion, and one revealing advertising table….

Consider the issue of routine mammography for younger women. In questioning the benefits of such screening, the United States Preventive Services Task Force ran afoul of Americans’ powerful draw to the notion of early detection in confronting an especially frightening disease. The USPSTF committed some political blunders in its approach to this freighted and genuinely complicated issue. It should have anticipated the powerful political, cultural, and commercial resistance it was likely to encounter.

In American popular culture–though not in the epidemiological data–breast cancer is often depicted as a young woman’s disease. A terrific 1998 paper by Paula Lantz and Karen Booth examined magazine depictions of breast cancer. Lantz and Booth concluded that “the increase in incidence is commonly portrayed as a mysterious, unexplained epidemic occurring primarily among young, professional women in their prime years.” Public service announcements concerning mammography and breast cancer show similar patterns. These announcements, with their myriad images of beautiful young swimmers, emphasize that one in nine women will be diagnosed with breast cancer. The PSAs do not emphasize that only about 12 percent of breast cancer patients are diagnosed before age 45.

Device manufacturers also have strong incentives to sell (and sometimes oversell) physicians, medical care organizations, and the public on the value of aggressive screening. Medical providers face equally strong financial incentives to aggressively image.

Consider this 2006 Siemens brochure titled Imaging Opportunities for Urology Physician Practices: Affordable In-Office Computed Tomography Solutions. (Jonathan Skinner of Dartmouth College provided this resource.) The brochure includes the following table.

Procedures per day Days per month Average [payment] Income Fair Market Lease Cost Return on Investment per month Return on Investment over five years
A 1.8 20 $220 $7,950 $7,950 Break-even Break even
B 5 20 $220 $22,000 $7,950 $14,050 $843,000
C 10 20 $220 $44,000 $7,950 36,050 $2,163,000

I can’t vouch for the exact numbers. Yet the general story is clear. Insurance reimbursements far exceed the additional costs of performing such imaging on each patient. This combination of heavy up-front costs and generous reimbursement create obvious incentives for high-volume use.

Distorting incentives extend beyond imaging. My KHN column draws upon a New England Journal essay by Smith and Hillner on cancer care. These authors cite a recent study by Jacobson and colleagues. These researchers document that oncologists responded to changes in Medicare reimbursement by shifting treatment in the direction of higher-margin cancer drugs. The overuse of costly supportive treatments such as Epogen creates related concerns.

Aggressive interventions are often much more lucrative than are equally valuable, less-intensive efforts such as the simple act of meeting with patients and their families. More disciplined pricing should be part of any sensible solution. Medicare and other payers pay too much or too little for key services. This pattern often wastes money. It creates further mischief by distorting how providers spend their day. Within many settings, providers are powerfully rewarded for following the most aggressive course that can be medically defended.

Medicare can address some of these problems through more careful pricing, diligent oversight of individual providers willing to push professional and regulatory boundaries, and comparative effectiveness research. Private insurers and managed care organizations might do the same—though I am less confident that either can fully address over-aggressive and sometimes harmful patterns of care. Medicare must overcome a difficult political economy in cancer care. Private managed care organizations face an even deeper problem. They lack the public standing to do what they are theoretically paid to do—manage patient care.

Ultimately, we need better institutional arrangements that command the clinical data, the bargaining power and incentives, and not least the legitimacy to balance humanity and restraint more effectively than we currently do. That’s one aspiration that motivates accountable care organizations.

Somehow, this needs to be done.

Harold Pollack is Helen Ross Professor of Social Service Administration at the University of Chicago. He is a contributor to Taking Note, the group blog of The Century Foundation.