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Should clinicians prescribe treatments that are more affordable but possibly less effective?
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Affordability of cancer treatments should be a critical factor in treatment decision-making.
The cost of cancer care in the United States is extremely high and continues to escalate. Because of increased cost-sharing requirements of health plans, patients may have to pay substantial amounts out of pocket for their treatments. Out-of-pocket costs can run thousands of dollars per month. It has been well established in the literature that, because of high out-of-pocket cost, patients may skip doses and delay or discontinue treatments. Nonadherence to cancer therapies may decrease OS and PFS. High out-of-pocket costs also may result in patients exhausting their savings, not being able to pay medical bills or declaring bankruptcy. Hence, affordability of cancer treatments is a critical factor when making treatment decisions.
The question of whether to prescribe a therapy that is less effective but more affordable than the standard of care is quite broad. Its answer depends on the extent of the differences in the effectiveness, safety and costs of the two drugs, as well as other factors such as cancer type, stage, and the patient’s age and employment status.
Oncologists can use evidence from comparative-effectiveness studies to determine if the more expensive therapy offers a clinically meaningful improvement in survival and quality of life. If the standard of care is equally, or only marginally, more effective but significantly more expensive, then physicians should consider prescribing the lower-cost alternative because patients are more likely to adhere to an affordable treatment.
However, the decision is more complicated if the standard of care significantly enhances survival, improves quality of life or is much less toxic. In this scenario, it is especially important for oncologists to discuss the costs and comparative effectiveness of treatments with patients and their family members. Patients ultimately will have a much better understanding of the financial impact of different levels of costs on their lives.
Oncologists may consider use of value frameworks to compare the costs and benefits of treatments. Value frameworks for oncology drugs have been developed by ASCO, Memorial Sloan Kettering Cancer Center (DrugAbacus) and Institute for Clinical and Economic Review. These frameworks may help oncologists decide if the new treatment is worth the additional expenses.
However, these frameworks may not help with understanding the patient’s liability for the treatment. Hence, selection of treatments using value frameworks should be supplemented with discussions of treatment costs with patients and family members.
Hrishikesh P. Kale, MS, is a doctoral candidate in pharmacoeconomics and health outcomes at Virginia Commonwealth University School of Pharmacy. He can be reached at kaleh@vcu.edu. Norman V. Carroll, PhD, is professor of pharmacy administration at Virginia Commonwealth University School of Pharmacy. He can be reached at nvcarroll@vcu.edu. Disclosure: Kale and Carroll report no relevant financial disclosures.
Value calculations should not be conducted at the bedside.
This important question comes at a time of rising cancer treatment costs and higher cost-sharing for insured Americans. Cost-conscious decision-aid tools are in development and aim to reduce treatment-related financial burden. Although decision-support tools are needed, I worry value calculations — and rationing — at the bedside could have limited impact on patient financial toxicity, worsen cancer care equity and fail to curb rising cancer-related expenditures.
I see three major limitations of conducting value calculations at the bedside.
First, patient perception of treatment benefit is frequently discordant with their treating oncologist, with patients attributing a higher magnitude of clinical benefit on average.
Second, it is unclear whether bedside cost discussions should focus solely on out-of-pocket costs, or consider broader insurer and society-level expenditures. Value-based discussions that consider out-of-pocket costs alone may influence treatment decisions and reduce patient financial burden; however, they are likely to fall short of tackling the larger problem of rising cancer-related expenditures.
Lastly, it is unclear whether cost transparency will significantly influence cancer treatment decisions, as individuals who face life-threatening illness may reasonably place more weight on their physical well-being than financial health.
Some health economists have pointed to the willingness of patients with cancer to go to the brink of bankruptcy as empirical evidence that cancer treatment is highly valuable to society and astronomical treatment prices are to be expected. Alternatively, as a clinician and health services researcher, I view cancer-related bankruptcy as a clear reason to improve safeguards against high out-of-pocket costs.
I fail to accept that the current level of cost-sharing is necessary or just for individuals receiving cancer care. “Skin in the game” may play an important role in some health care settings (eg, nudging patients toward a generic rather than branded statin), but its function in cancer care is less clear because clinical scenarios with truly comparable substitutes are infrequent. Further, the current level of cost-sharing — potentially hundreds to thousands of dollars a month — serves more as a barrier to cancer treatment than an effective tool to influence patients to choose a higher-value therapy.
Overall, we should applaud the efforts underway to distill complex clinical trial data, comparative-effectiveness research and patient-reported outcomes into digestible decision tools. However, it is important to recognize that — although a drug’s benefit and toxicity ratings are derived from empirical data — a drug’s price is relatively arbitrarily set and can vary with market forces.
Health care delivery in the United States is changing and value calculations may be shifting away from the bedside toward the level of the insurer. With input from various stakeholders, including patient groups, value-based insurance offers the potential to better align drug prices/reimbursement with clinical value, reduce patient out-of-pocket costs and deliver more equitable cancer care.
If we fail to adopt value-based insurance in the United States, efforts to reduce overall health care spending will continue to transfer rising health care costs onto vulnerable individuals, forcing many of our patients to make difficult decisions between their physical and financial well-being.
Scott Huntington, MD, MPH, MSc, is assistant professor of medicine in the section of hematology at Yale University. He can be reached at scott.huntington@yale.edu. Disclosure: Huntington reports no relevant financial disclosures.