Researchers have discovered that recent increases in Medicare spending on outpatient end-of-life cancer care may have been driven almost entirely by costs associated with immunotherapy, which is given to fewer than one in five patients, according to a new study published by Mantz et al in the International Journal of Radiation Oncology • Biology • Physics. For patients with cancer, outpatient care typically accounts for 60% to 70% of health-care costs in the last 6 months of life. Analyzing Medicare Part B claims data for nearly 85,000 beneficiaries, researchers found that spending for this type of care rose 12% from 2015 to 2019, and that payments for immunotherapy drug costs accounted for 84% of the net increase.
“Our study is the first to quantify trends in utilization and costs across the different types of outpatient cancer services for Medicare beneficiaries who are at the end of life," explained lead study author Constantine Mantz, MD, FACRO, a radiation oncologist and Chief Policy Officer at GenesisCare. “We found that the growing use of immunotherapy agents led to an outsized acceleration in costs for this group,” he added.
Study Methods and Results
Payments related to immunotherapy, hormonal therapy, chemotherapy, and ancillary drugs rose 30% during the study period. In contrast, payments for radiation oncology—the other primary modality in palliative cancer care—decreased by 2%.
The researchers noted that the small drop in radiation oncology spending likely reflected the field’s movement toward hypofractionated radiation treatments involving fewer individual treatment sessions—which lowers costs.
Conclusions
“As a result of hypofractionation, we saw a net decrease in expenditures related to radiation therapy, even though the proportion of patients who received this treatment remained the same,” Dr. Mantz highlighted. “We don't see that with drug therapy—instead, we see a large net increase.”
The researchers emphasized that the use of immunotherapy in end-of-life outpatient care can be controversial because of its risk of side effects as well as higher costs.
“If the trade-off for side effects and higher costs is improved survival and quality of life, then I’m entirely supportive. We can argue about what the price may be, but I don’t think we can argue about the net benefit provided to the patient in terms of their overall health,” Dr. Mantz underscored. “What can be problematic is the continued use of a treatment that imposes some meaningful risk of side effects for patients approaching the end of life. We have to get better at recognizing who those patients are near the end of life and, when appropriate, transitioning them to less risky, less expensive therapies,” he concluded.
The researchers expressed that more effective metrics are needed to help physicians better identify these patients, as is better communication between physicians and patients with a terminal illness about end-of-life care options—including palliative and hospice care programs.
Additionally, forthcoming changes to the way Medicare negotiates drug prices and expanding the use of biosimilars for anticancer drugs may also offer opportunities to lower medication costs.
The recent passage of the Inflation Reduction Act granted the Centers for Medicare and Medicaid Services greater bargaining power with manufacturers in an effort to tamp down escalating drug costs—and may lower the financial burden for outpatients with cancer who are receiving end-of-life care.
Disclosure: For full disclosures of the study authors, visit redjournal.org.
