Systemic improvements needed to afford cancer care of the future

Questioning cost effectiveness, providing high quality care for all citizens and paying attention to the value of new innovation are needed to combat high costs.

According to the National Institutes of Health, the United States spends about $2 trillion on health care per year, about $89 billion of which is spent on cancer care. Despite concerns surrounding the future costs of cancer care, our nation can afford them, according to Neal J. Meropol, MD, director of the Gastrointestinal Cancer Program at Fox Chase Cancer Center.

“Cancer care is not immediately going to bankrupt the economy, but it’s emblematic of basic concerns that exist regarding health care expenditures,” Meropol told HemOnc Today. “There’s an important focus on people with cancer because they are a vulnerable population facing a life-threatening illness and are facing increasing out-of-pocket expenses.”

Meropol presented information on pharmacoeconomics and the future costs of cancer care at the 2009 Great Debates and Updates in GI Malignancies meeting in New York. HemOnc Today spoke with Meropol, who is also an adjunct senior fellow at the Leonard Davis Institute of Health Economics at the University of Pennsylvania, about the costs of cancer care in the future, how technology affects expenses and what can be done to combat inevitably increasing costs.

The cost of cancer care and the economy

According to Meropol, though cancer drugs account for only a small percentage of overall health care costs, the growth rate of spending on health care exceeds the growth of the entire economy. It is a problem that cannot continue indefinitely. As a society, we spend more per person on health care than any other industrialized country with little to show for it. During his presentation, Meropol used life expectancy as an example: We spend more money per person on health care, but our life expectancy is not superior to that of any of the countries that spend less.

However, the discrepancy exists due to a lack of interest in the cost effectiveness of emerging cancer therapies. According to Meropol, other countries have explicit thresholds for payment decisions, whereas the United States does not. Therefore, society finds it acceptable to pay $180,000 for colon cancer drugs that will extend survival by only a year or two. According to Meropol, treatments are most cost effective in the adjuvant setting.

Technology driving costs

Because new technology is costly, advancements in cancer drugs and therapies are considered one of the driving forces behind the growth in health care spending.

“Because cancer treatment has been sacred and untouchable, vis-a-vis insurance reimbursement, this has been a very fertile place to invest in new technology,” Meropol said.

Successes made in the fight against cancer can be attributed to the attractiveness of investing in cancer care, he said. If for some reason the incentive to invest in cancer care declines, the private sector will be less likely to put money into oncology.

Ongoing research and new technologies have increased the feasibility of individualized medicine, an area in which the future seems uncertain, according to Meropol. Although personalized medicine may reduce the potential market for certain more established treatments, it also has the potential to open new markets. Increasing the efficacy of personalized therapies will also increase their value, therefore increasing their worth for the high price they might require.

The affect on patients, doctors

Currently, the cost of cancer care has a significant effect on patients. One-third of families faced with cancer spend at least 10% of their disposable income on medical care, and 25% of people polled by USA Today reported using most or all of their savings to pay for out-of-pocket expenses, according to Meropol.

“During the last five years or so, there’s been a quantum increase in the cost of new cancer therapies and this cost is being increasingly passed on to the consumer for the use of co-pays and deductibles,” Meropol said. “At the level of individual patients, the out-of-pocket financial burden is becoming increasingly important, such that patients now have to make decisions about their care based on what it’s going to cost them.”

During his presentation, Meropol discussed patients’ uncertainty regarding how they should ask about cost, where they can obtain information to discuss costs with their families and how these concerns ultimately affect oncologists.

“Oncologists feel ill-equipped to consider costs. When talking about cost and value we’re not necessarily going to predict the costs of therapy; it takes a lot of time and we feel conflicted between our responsibility to society and to individual patients,” Meropol said during his presentation. “We don’t have the resources to help us navigate this either.”

According to recent data, patients want to discuss costs, but it rarely happens because not all oncologists feel comfortable having that discussion with patients. However, it has been shown that the cost of treatment does affect decisions oncologists make in terms of which treatments they may or may not recommend.

“For me, the biggest issue is the potential for increasing health care costs to widen disparities in cancer outcomes,” Meropol said.

Increasing insurance premiums increase the burden on patients, whether or not they are insured. But the problem is intensified among the rising number of patients without insurance. As an example, Meropol relayed the fact that patients with colon cancer who do not have health insurance are more likely to be diagnosed with disease at a higher stage and have worse survival rates.

Solutions to curb excessive costs

Though cancer care accounts for only 5% of overall health care spending, that percentage is increasing. Despite this, the goal should be to provide high quality cancer care for all citizens, according to Meropol.

“Personalized medicine may have unintended economic consequences for the whole cancer care enterprise and policy solutions do need to integrate various perspectives and ultimately address what, in essence, are finite resources that we as a society have to distribute,” he said.

In addition, Meropol said that special attention should be paid to the value of new innovation in a way that our society has not been prepared to in the past. – by Stacey L. Adams

For more information:

• National Survey of Households Affected by Cancer. USA Today, Kaiser Family Foundation, Harvard School of Public Health. 2006.
• Meropol NJ. Pharmacoeconomics: Can we afford the cancer care of the future? Presented at: Great Debates and Updates in GI Malignancies; April 3-4, 2009; New York.
• Fiscal Year 2007 Budget Request House Subcommittee on Labor - HHS - Education Appropriations. National Institutes of Health website.