I read the article about “The Ethics of Rationing Cancer Care” with interest (The ASCO Post, Dec 15, 2012). The issue of rationing (or rational) care has likely been debated since Hippocrates. Yet the topic has become a focus of acute interest with the current fiscal crises facing countries around the world.
Cancer consumes 5% of all medical costs and 10% of Medicare spending. For advanced noncurable cancer, there are many high-cost, marginal-benefit therapeutic options whose judicious use could help solve the burgeoning severe fiscal crises.
At a recent tumor board meeting at our institution, the question was asked, “When is cancer care excessive?” The response from a primary care physician was, “When the care deprives resources from ‘more useful’ care like prenatal care, or when research and drug costs deprive resources better applied toward lifesaving drugs like antibiotics.”
‘Skin in the Game’
Prioritizing health-care spending and weighing the cost-benefit of treatments makes eminent sense. With the limited success of noncurative treatments in improving quality and length of life, decisions to opt for such treatments should be shared by patient and family. Family members should also be involved in sharing the patient’s costs. Thus, patient and family can weigh for themselves the costs against perceived benefits (aka “skin in the game”).
In one possible model, well-proven, effective palliative measures might be fully covered by insurance. The patient’s shared cost of second-line cancer therapy could be determined at 20% (as an example). The shared cost of third-line therapy might be 30%, and the shared cost of fourth-line therapy might be 40%. Making the patient and family increasingly vested with the effectiveness of therapy would reduce the use of cancer drugs for marginal benefit, as well as reduce the cost of these agents.
Cost control of drugs is not the only concern. Specialized surgical and nonsurgical procedures may be similarly evaluated. For example, stereotactic radiosurgery may be the optimum therapy for a solitary brain metastasis, but it is considered third-line therapy for a case involving nine brain lesions. Overutilization of various other expensive diagnostic and therapeutic technologies could also be evaluated and better defined.
With the patient and family’s greater involvement, the individual oncologist would not be anguished in denying tests and treatments with marginal benefits. Yet the family and patient can have the satisfaction of determining whether “every option has been exhausted” for their loved one.
The oncologic community (like the developers of National Comprehensive Cancer Network guidelines) would be charged with better defining which therapies are considered first, second, and third line. Scientific rationalization of cost and extent of benefit will also encourage physicians to think specifically of therapeutic benefits and other alternatives. Thus, we can provide patients the optimum value and benefits of “evidence-based medicine” as well as “comparative effectiveness research.”
Need for Specialty Leadership
While it is important to evaluate cost-benefit of cancer care, the field of oncology needs to take a fundamental look at what drives the cost of cancer care services, technologies, products, utilization, and reimbursement. This involves our specialty leaders looking at the structural component of the cost of drugs (business practice, research, production, marketing), technology (manufacturing of diagnostic and therapeutic radiology equipment and utilization), and practice patterns (geographic patterns of care, including self-referral).
Hopefully, such an evaluation will curtail the health-care marketing wars and medical technology arms race (and resulting overutilization) that has gripped many regions of the country. Regional and local patterns of care (Surveillance, Epidemiology and End Results data and billing data) could be used to address issues of waste, redundancy, and overutilization on the part of all stakeholders (patients, doctors, hospitals, insurance carriers).
We should not make health care a political issue. But if the medical profession does not address these self-created problems, the fiscal stability of the country is at stake, and the political debate becomes inevitable. ■
—Gilbert A. Lawrence, MD, DMRT, FRCR
Radiation Oncology, Faxton Hospital
Utica, New York