Cost Considerations Change Dialogue
Although financial concerns are increasingly influencing choices in cancer therapy, barriers to cost discussions between physicians and patients often limit the scope of such discussions. Incentives for oncologists to use high-cost interventions and patients’ perceptions that cost consideration equates to second-class care are but 2 barriers to meaningful cost discussion.
The issue of addressing the cost of cancer care with patients was examined in an educational session at the 2010 American Society of Clinical Oncology (ASCO) annual meeting.
Traditionally, physicians were warn ed to avoid limiting treatment based on cost considerations, with the belief that all patients should be treated the same regardless of their ability to pay, said Lidia Schapira, MD, assistant professor, department of medicine, Harvard Medical School, Boston, MA. But an ethical detour has emerged in the past few years—physicians are now expected to provide advice to patients regarding the treatments that best meet the patients’ interests and values.
However, the value attached to a treatment is not always easy to quantify, said Dr Schapira, and may depend on the expectations of the patient and the clarity of the information that he or she has received. “Patients come with ideas, and perceptions of gain…based on a concept that is not clearly shaped in their minds,” she said.
Further barriers to cost discussions include the mixed loyalties of physicians as both drivers of medical costs and advocates to patients. In addition, there is the embarrassment that patients may feel about discussing finances with their doctor and that “they may not want us to modify a recommendation if we have a suspicion that perhaps they’re not able to pay,” she said. Also, too little time is allotted during appointments to have cost discussions, and patients are often unwilling to mention cost concerns to avoid influencing the doctor’s recommendation.
Surveys have shown that doctors are indeed willing to have cost discussions with their patients. Oncologists, however, believe that “there are not enough data to guide them in these conversations and that makes these conversations difficult,” said Dr Schapira.
One such survey of 787 ASCO members1 found that 84% strongly or somewhat agreed that patient out-of-pocket costs influence their treatment recommendations. Less than half (43%)
responded that they frequently or occasionally discussed the cost of new cancer treatments with their patients.
Eighty percent of patients expressed a desire for more use of cost-effectiveness data in coverage and payment decisions for cancer drugs. Only 42% agreed that they were well-prepared to interpret and use cost-effectiveness information in their treatment decisions. Seventy-nine percent favored more comparative effectiveness research.
What Physicians Are Doing
Very little is known about how patients prefer cost issues be discussed, said Deborah Schrag, MD, MPH, attending physician/oncologist, Dana-Farber Cancer Institute, and associate professor of medicine, Harvard Medical School, Boston.
The vantage point of physicians is that they have a big influence on decisions, but “we ourselves are pulled in quite a few different directions,” she said. Physicians hold the belief that care should be equitable and do not view their roles as economic advisors even as they recognize that many interventions have limited value.
Dr Schrag’s survey of medical oncologists found that 30% discussed the cost of cancer treatment most of the time, 30% discussed it some of the time, and 16% refused to discuss cost at all.2 Approximately 80% either strongly agreed or agreed that oncologists have a responsibility to consider the impact that treatment decisions may have on the patients’ financial well-being.
The quality-adjusted life-year (QALY) is a standard measure by which cost can be compared across interventions and compared side by side, said Dr Schrag. Currently, an intervention with a QALY less than $100,000 is regarded as meeting the cost-effectiveness threshold for US healthcare interventions. Translating cost into value is a constantly shifting landscape, however, as new treatments, new benefit design plans, and patent expirations emerge, she said.
Ill-aligned incentives may also be preventing the use of cost considerations in patient management. Physicians have strong incentive to use high-cost interventions, although evidence exists that they can be motivated by economic incentives, such as off-label use of expensive treatments and a preference for on-patent versus off-patent agents. In addition, “treating with therapies of marginal utility is often the path of least resistance,” said Dr Schrag.
The forecast is for change in cancer care delivery, she said, with realignment of incentives. A greater emphasis on the cognitive/compassionate component of care is in the offing, along with streamlined, coordinated guideline-driven care, and less reliance on delivery of expensive chemotherapy and a shift away from the predisposition to think that “more is better.”
Moving forward, the solution may lie in more comparative effectiveness research, believes Dr Schrag. However, “it requires large-scale data collection and greater investment in intraoperable systems to track outcomes and figure out what’s valuable and thereby take a back-door approach to the cost issue.”
- Neumann P, Palmer JA, Nadler E, et al. Cancer therapy costs influence treatment: a national survey of oncologists. Health Aff (Millwood). 2010;29:196-202.
- Schrag D, Hanger M. Medical oncologists’ views on communicating with patients about chemotherapy costs: a pilot survey. J Clin Oncol. 2007;25:233-237.