The American Society of Clinical Oncology (ASCO) has put forth a proposal to its membership to consider all factors, including costs, when deciding the best treatment for patients. While being aware of costs is unavoidable in health care today, it is important not to lose sight of how new treatment options enable a more personalized approach to medicine that benefits patients, the healthcare system and the economy.
“I don’t think doctors should be factoring costs into their decisions,” Scott Gottlieb, M.D., resident fellow at American Enterprise Institute, said. “It’s not transparent to the patient when the doctor is adjudicating those things because a patient might not know what wasn’t offered to them because the doctor was financially conflicted.”
In medical school, doctors take a Hippocratic Oath, swearing to do what is in the best interest of their patient’s health without compromise. Pressuring doctors to ration care creates a conflict of interest.
“There should be forces in society who should be concerned about the budget, about how many MRIs we do, but they shouldn’t be functioning simultaneously as doctors,” Martin A. Samuels, the chairman of the neurology department at Brigham and Women’s Hospital in Boston, told the New York Times. According to Samuels, doctors could lose their patients’ trust if they say, “I’m not going to do what I think is best for you because I think it’s bad for the health care budget in Massachusetts.”
By focusing on head-to-head comparisons, policymakers often fail to consider the personalized nature of disease.
Most doctors seem to agree with Samuels. According to a survey published in the Journal of American Medical Association, 64 percent of physicians said the majority of responsibility for reducing health care costs should lie with others in the health care system. Seventy-three percent also believe that physician professional societies should not have a major role in reducing health care costs.
The Affordable Care Act (ACA), however, introduced several payment models that shift financial risk away from insurers and onto doctors and patients. For example, the ACA encourages bundled payments, which provide a lump sum payment to providers for an episode of care. Under this type of model, providers would have a financial incentive to provide the lowest cost care, which could have a negative impact on quality of care for patients.
Prescription drug costs remain a relatively small percentage of care costs. Overall, cancer care continues to make up just 5 percent of U.S. health care spending. And cancer medications accounted for less than 1 percent of the country’s total health care budget in 2011. Meanwhile, hospital care made up 32 percent, and physician services made up 20 percent.
“Of course, they should be looking at more than therapies, but the technology becomes a much easier way to try to ration cancer care because it’s visible,” Gottlieb said. “It’s suboptimal, but it’s politically expedient.”
Changes in cost-effectiveness policies that have been used by other governments could offer patients better access to life-saving medications. For example, if the United Kingdom’s drug rationing agency had a wider view of the societal benefits of innovation, patients would have novel medicines in 226 new indications. As a result, cancer patients such as Colin Ross might not have had to fight in court to gain access to effective therapies deemed cost-prohibitive for patient care.
By focusing on head-to-head comparisons, policymakers often fail to consider the personalized nature of disease. In a study of pancreatic cancer patients reported in Pancreas, researchers found little to no overlap between the genetic mutations associated with each patient’s cancer. This may help to explain why cancer patients have different responses to a given therapy.
When the number of treatment options available increases, patient population benefits overall. In one study that looked at cancer mortality rates in the United States between 2000 and 2009, researchers found that fatalities fell by 14 percent mostly due to an increase in new treatment options.
“You’re recognizing all the costs of the treatment right now, but you’re going to be recognizing the benefits over the next thirty years,” Gottlieb said. “The system isn’t well adapted to doing that, making those kinds of trade-offs.”