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Value Propositions

October 2010, Vol 1, No 5

Stopping Hospice Care Boosts Healthcare Costs
Care costs for patients who disenrolled from hospice care were nearly 5 times higher than for patients who remained with hospice, a new study finds (J Clin Oncol. 2010;28:4371-4375). Medicare data from 90,826 patients with cancer served by 1384 hospices were analyzed, and nearly 11% of patients disenrolled from hospice care. Nearly 34% of disenrollees were admitted to an emergency department (vs 3.1% who remained in hospice) and nearly 40% were admitted as hospital inpatients (vs 1.6% in the hospice group). Overall costs from time of hospice enrollment until death were $6537 in the hospice group versus $30,848 among those leaving hospice.


Similar Thoughts on Cancer Costs in the United States and Canada
A survey comparing US (n = 1355) and Canadian (n = 238) oncologists’ attitudes toward costs, cost-effectiveness, and health policies regarding expensive cancer drugs (J Clin Oncol. 2010;28:4149-4153) finds attitudes generally similar despite the differences in healthcare systems. The overall response rate was 59%; more US than Canadian oncologists favored access to effective treatments regardless of costs (67% vs 52%), and more Canadians favor access to treatments only if they are cost-effective (75% vs 58%). A majority of oncologists favor expanded use of cost-effectiveness data in coverage decisions (80% US, 69% Canadian), but fewer than half in both countries feel well-equipped to use this information. Determining the value of drugs should be the responsibility of physicians and nonprofit agencies, as indicated by oncologists in both countries.


Robots Taking Over as Cost Driver
“It is unlikely that robot-assisted surgeries will completely replace conventional surgeries for the full range of procedures for which cost studies have been done. If such a substitution did occur, however, it would generate nearly $1.5 billion in additional healthcare costs annually—excluding the (amortized) cost of the robots, which would bring the total to more than $2.5 billion.” —From a perspective in the New England Journal of Medicine (2010;363:701-704) examining the reasons for growth in robotic surgery use and the associated costs. The authors suggest that comparative effectiveness research could rein in the fragmented decision-making that has led to this growth. Also see Value-Based Cancer Care, September 2010, page 19, for more on robotic surgery in prostate cancer.


New Healthcare Environment Demands New Focus on Costs
“The exciting explosion in new medical treatments creates an economic challenge that cannot be ignored. The pricing of medications and other interventions is one issue to consider, but the range of patients in whom the treatments are used—beginning with patients in whom the treatments may be most beneficial and cost-effective but rapidly expanding to those for whom the benefit and cost-effectiveness may be less clear— should also be considered.” —From an editorial in the New England Journal of Medicine (2010;363: 1278-1280) discussing a study showing clinical benefit in fondaparinux (Arixtra) use for superficial-vein thrombosis in the legs. Even with positive clinical findings, the economic component of drug therapies cannot be overlooked, the authors say, and they recommend that the FDA push for “phase 3.5 trials” to document cost, quality of life, and cost-effectiveness of new therapies.


Hard Times Bring Medication Discontinuance
A letter to the editor in the August 5 issue of the New England Journal of Medicine (2010;363:596-598) describes how 3 patients of a California practice who had metastatic gastrointestinal stromal tumor discontinued imatinib therapy as a result of economic hardship. High-dose imatinib can restore control to tumors refractory to other treatments, but the retail cost can exceed $4500 per month. One patient discontinued treatment because of decreased earnings; the second patient was unable to purchase an affordable insurance policy because of the preexisting condition, and the last patient stopped taking the drug after his business failed. The practice now emphasizes the importance of medication adherence, referring patients to social workers and financial counselors, and providing information about drug manufacturers’ patient-assistance programs.


Economic Downturn Threatens Cancer Prevention Gains
A special issue of the European Journal of Cancer (September 2010;46[14]) focused on cancer prevention considers a number of ways that economic pressures fostered by the current global financial crisis could impact cancer rates. Public donations to cancer research and government and industry funding of research may decrease, and occupational exposure to carcinogens may increase as safety shortcuts are taken, thereby boosting cancer rates. On the reduction side, people may reduce unhealthy and cancer-causing habits to reduce personal expenditures, or governments may increase taxes on unhealthy goods such as tobacco.


Putting Economic Reality into Medical Classrooms
A JAMA commentary (2010;304:1229-1230) urges that medical education be expanded to include economic considerations as part of the curriculum. The authors argue that a core, required course covering economic factors that shape medical research, available treatments, development of clinical guidelines, and definition of diseases, as well as the players affecting cost and consumption, and the interactions of these forces, should be created. Second, a revision of the medical school curricula that reflects the core course should be undertaken. Instead of considering economic forces as extraneous, physicians need to realize their dual role as patient advocates and allocators of resources, the authors say. Also see “Guiding Patients Through Cost-Based Treatment Choices” (cover) for more on physician–patient economic discussions.


NIH Makes Pharmacogenomics Push
Targeting drug therapies through genomic information can improve patient outcomes, and the National Institutes of Health (NIH) has recently announced several grants that will foster research in the area of pharmacogenomic research. The first one, a $15-million grant over 5 years, will support the Pharmacogenomics Knowledge Base (PharmGKB), which began in 2000 as a catalog of links between human genetic variation and drug responses. PharmGKB genetic information was used by a worldwide team of researchers in 2009 to better predict optimal warfarin dosing. A second grant of $161.3 million over 5 years will expand the Pharmacogenomics Research Network, which has already discovered gene variants linked to responses for treating several cancers, heart disease, asthma, and nicotine addiction.

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