The Costs of Care: A Discussion We’re Not Prepared to Have—Yet

November/December 2010, Vol 1, No 6
Denise K. Pierce
DK Pierce & Associates
Zionsville, IN

Each year, oncologists return to their respective practices after attending the annual American Society of Clinical Oncology or American Society of Hematology meetings armed with knowledge of new drug/biologic combinations, modified regimen dosing, and other novel approaches that may provide incrementally better outcomes for cancer patients. But because the focus at these meetings has remained primarily clinical rather than on the cost effectiveness of individual drugs or regimens, progress in developing and accepting consistent pathways, or in considering cost-effectiveness data and value-based treatments for the patient and the healthcare system has been slow.

The above article summarizing the attitudes of US and Canadian oncologists regarding costs, cost-effectiveness, and health policies associated with new cancer drugs, neatly illustrates how physicians in both countries face these issues, and raises a matter of great sensitivity for the oncologist. Fewer than half of the physicians in both the United States and Canada always or frequently discuss the costs of cancer treatments with patients, according to this survey. This corresponds with the 2007 survey by Schrag and Hanger conducted with 167 practicing oncologists, wherein 42% discussed cancer treatment costs always or most of the time, 32% sometimes did, and 26% rarely or never did.1

Cancer and Cost: An Essential Conversation

It is understandable that oncologists have an aversion to conducting these conversations; however, financial counseling is indeed a significant and growing role in oncology practices across the United States.A2010 survey by Kantar Health, conducted on behalf of the Association of Community Cancer Centers, outlined that 88% of the 84 responding cancer programs integrate financial counseling related to the cost of treatment.2 In addition, one need only Google key words such as “oncology financial counselor” to see the hundreds of resulting hits. These results include information from community-based oncology practices and comprehensive cancer centers regarding the role of the financial counselor to help patients better understand health insurance benefits and costshare responsibilities.

One example of why financial counselors are now so important to oncology is exemplified by a 2009 study of the AARP Public Policy Institute.3 This study assessed changes in patient cost share of chemotherapy specific to the Medicare Advantage (MA) managed care plan environment, and found that in 2009, only 21% of MA beneficiaries paid a fixed copayment amount for chemotherapy (down from43%of beneficiaries in 2008). By 2009, MA plans had evolved to where 80% of beneficiaries required a coinsurance cost share—commonly 20% —of the medical cost of chemotherapy. For this cost share, the patient cannot obtain a supplemental insurance coverage (as compared to a beneficiary under fee-forservice Medicare). The MA example is but one of many scenarios increasing the economic constraints on patients.

Conversations on costs of care and the implications of these costs to patients are necessary, but the oncologist infrequently plays the role of financial counselor. Social workers or dedicated insurance reimbursement specialists commonly better handle the ongoing demands of understanding confusing insurance requirements, discussing the overall cost of care and financial responsibilities, and helping patientsmanage ongoing issues of paying copays and coinsurance for their care.

But beyond being discomfited by these conversations or possessing knowledge of insurance programs, physicians in both countries also reported feeling unprepared at a very fundamental level. Only 42% of US physicians strongly or somewhat strongly agreed that they were wellprepared to interpret and use costeffectiveness information in treatment decisions, while 49% of Canadian doctors felt this way. Clearly, more education in this area will be needed if costs and cost effectiveness continue to assume a larger role in healthcare decisions. A recent commentary argued that economic realities need to be better incorporated into medical education;4 although this commentary focused on biggerpicture economic components and relationships, one of the points raised— that “cost-sensitive care can be compatible with and, indeed, serve patient needs and physician responsibilities” is also pertinent to the matter of cost effectiveness.

Cancer remains a diverse and challenging disease to treat no matter which side of the border and, despite the preference to avoid discussions about cost of care—whether among their colleagues or with patients oncologists will continue to face increased pressure to apply cost effectiveness in relation to clinical outcomes within that diversity.

References

  1. Schrag D, Hanger M. Medical Oncologists’ views on communicating with patients about chemotherapy costs: A pilot survey. J Clin Oncol. 2007;25:233-237.
  2. Association of Community Cancer Centers. Cancer Care Trends in Community Cancer Centers, 2009- 2010. General introduction accessed on October 23, 2010 at: http://accc-cancer.org/surveys/pdf/Cancer_ Care_Trends-2010-Gatefold.pdf
  3. AARP Public Policy Institute. Medicare Advantage Benefit Design: What Does It Provide, What Doesn’t It Provide, and Should Standards Apply? March, 2009. Accessed on October 23, 2010 at: http://assets.aarp. org/rgcenter/health/2009_03_medicare.pdf
  4. Sessions SY, Detsky AS. Incorporating economic reality into medical education. JAMA. 2010;304: 1229-1230.

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