Addressing the Societal Impact of Financial Toxicity

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“Costs of drugs should be associated with benefit, safety, and expenses involved in developing and producing the drugs, not simply with what the market was willing to pay for the last new drug.”
— Jeffrey Peppercorn, MD, MPH

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Most discussions about “financial toxicity” center on the cancer patient, but there is also a societal toxicity, which has far-reaching consequences. Coming up with answers to this growing problem has vexed health-care experts over the past decade. In an effort to gather opinions on this vital issue, The ASCO Post recently spoke with Jeffrey Peppercorn, MD, MPH, a hematologist/oncologist at Massachusetts General Hospital with a special interest in health policy. 

Discussing Costs With Patients 

Studies indicate that most patients with cancer want state-of-the-art therapies regardless of costs. Is it realistic to think that busy community practitioners can have a cost/value discussion with a cancer patient facing a life-threatening disease? 

I think that most of us, if faced with a life-threatening cancer, would want the best treatment available, and we want hope. This makes it very hard to introduce the question of cost into a discussion of treatment options that have marginal benefit. I am not convinced that this is ethical or the best way to approach this issue. 

I think patients do want to know what they will have to pay out of pocket for care. They don’t want to be surprised, and the direct financial burdens of cancer therapy can be substantial. But preparing patients for costs of care, being transparent about costs, or trying to help patients address costs to gain access to appropriate therapy is different from considering costs up front as a way to make treatment decisions. 

So, no, I don’t think busy community oncologists are going to have detailed cost/value discussions. I am not sure that is the best strategy to get the results we want, which is greater use and guaranteed access to high-value therapy, with less or no use of low-value therapy. That work probably should be done outside of the doctor-patient discussion. 

Reimbursement Issues 

Does the current reimbursement system for oncology practices play into this discussion? 

I think this is less and less of an issue, and I hope that my colleagues are not making treatment decisions on the basis of their own reimbursement. The current reimbursement system does push oncologists (and all doctors) to see more patients and spend less time talking, but that is a problem for many reasons, beyond discussions of costs of care. 

Drug Costs 

Since most cancer patients are older, the financial burden for expensive oncology drugs falls on Medicare, which is not chartered to look at value or negotiate drug prices. Please share your thoughts on this entrenched dilemma. 

We still need better treatments, so we want to continue to incentivize innovation, which means, in part, paying for new drugs. But there is a clear disconnect between the value or relative benefit of a new drug and its costs. 

Costs of drugs should be associated with benefit, safety, and expenses involved in developing and producing the drugs, not simply with what the market was willing to pay for the last new drug. It seems clear that some form of negotiation around drug prices or standard of cost-effectiveness needs to be applied. 

Other countries that negotiate drug prices still struggle with the balance between access to novel therapy and cost control. In the United States, we have an extreme position, in that we won’t even talk about cost-effectiveness on the Federal level, and this makes no sense. 

Oncology Payment Model 

Numerous alternative payment models in health care have been discussed, but nothing seems to stick. What is your opinion of the oncology payment model in the context of societal costs? 

The advantage of a fee-for-service model is that it allows for physician discretion and reimburses for care delivered. If the physician practices evidence-based medicine and acts in the patient’s interest, I have no problem with this. However, we know that this tends to incentivize overtreatment and tends not to incentivize thoughtful discussions that can result in less intervention. Despite the ideal of physician behavior, it does not incentivize quality and is a not a good way to control cost. 

The oncology payment model, which provides capitated payments and then a quality-improvement and cost-lowering incentive, has the potential to provide the same care at a lower cost and to foster innovation in more efficient care delivery. Capitation in various forms has been tried before and can potentially incentivize less care or incentivize clinicians and practices to take care of less complicated patients. I am in favor of payment model exploration and innovation, but we need to see the data. 

I suspect that in many areas, we will see that excellent care can be delivered at a lower cost. I remain concerned that we are so focused on the cost-control side of oncology. That priority exists for good reason, but we also need to pay attention to the fact that good care with novel effective drugs may cost more money, and as a society, we may need to invest more in care delivery in some areas. In addition, we need to invest in both clinical and health services research that can improve treatments and teach us how best to provide quality care at a sustainable cost. ■

DISCLOSURE: Dr. Peppercorn has received research support from Pfizer and the Greenwall Foundation for Bioethics, and his spouse is employed by GlaxoSmithKline.