The financial nonsustainability of the healthcare system and the use of evidence-based guidelines to guide clinical practice are on a collision course, according to cancer experts who participated in a roundtable discussion on the economic issues affecting cancer care. The panel was held during the 15th annual conference of the National Comprehensive Cancer Network (NCCN). The discussion focused on the challenging question of how to pay for the increasingly costly care of cancer. The panel included payers, physicians, patient advocates, and industry experts.
Guidelines Inform Coverage
Representatives from Aetna and UnitedHealthcare said their companies use the NCCN guidelines to make coverage decisions. Both plans pay for any treatment that receives a category 2B or higher recommendation. Although patients and providers argue that much of cancer treatment is not covered, these payers disagreed. James D. Cross, MD, Head of Medical Policy and Program Administration for Aetna, said it is "extraordinarily rare that treatment is denied by Aetna in a lifethreatening illness." He said that Aetna has found that when guidelines are followed, cost of care is 35% lower.
Controversies over reimbursement become thornier once the recommended treatments have been exhausted, the panelists agreed. Nancy Davenport-Ennis, President and CEO of the National Patient Advocate Foundation, praised "courageous" physicians who find experimental treatments that keep patients alive, but Dr Cross criticized this approach, maintaining that oncologists should not just "take things off the shelf" but should enroll patients in clinical trials.
Participants agreed that active treatments at the end of life are not only futile but are often detrimental. "Costs aside, let's not expose patients to harm with little chance of benefit," said Lee Newcomer, MD, Senior Vice President of Oncology Services with UnitedHealthcare. He said that the cost of end-of-life care is not necessarily much greater than other cancer care. "We busted that myth," Dr Newcomer said, referring to a UnitedHealthcare analysis that showed most costs to be related to hospitalization for complications, except for leukemia and lymphoma. "We didn't see a sudden surge in chemotherapy and other treatments," he said.
Drug Development Is Also Affected
Douglas Lind, MD, of GBP Capital, a venture capital company, noted that concerns over reimbursement have also hit the research and development arena. His company no longer looks for drugs with the potential for US Food and Drug Administration approval but for drugs with the best likelihood for reimbursement. "For the first time this is the central question," he said, adding that pharmaceutical companies "are equally asking this question."
The oncologists on the panel, Al B. Benson, III, MD, of the Robert H. Kurie Comprehensive Cancer Center of Northwestern University, and Joseph Bailes, MD, Chair of the American Society of Clinical Oncol ogy's Government Relations Council, expressed dismay. "Many of the innovations in medicine are a result of thinking outside the box," Dr Benson pointed out; Dr Bailes added that "inefficiencies often lead to innovations."
Financial Crisis of Patients with Cancer
For many patients, the talk about cost-containment comes too late, Ms Davenport-Ennis said. Her organization has witnessed an 87% increase in the number of families filing for bankruptcy because of medical debt.
Dr Newcomer acknowledged that health insurance has become unaffordable for many consumers, but Ms Davenport-Ennis said that 75% of bankrupt consumers are fully insured. "Be aware that the American consumer is bellying up to the bar to try to pay for healthcare and is slipping into bankruptcy," she said.
Industry representatives reminded listeners that financial hardships are not the sole province of the patients. Jason Slotnik, Esq, with the Washington, DC–based legal firm Foley Hoag, said that industry needs to be able to recoup its investment, the magnitude of which is growing greater as more capital is required in drug development. Demonstrating cost-effectiveness, for example, adds about $200 million to the cost of bringing a new drug to market, Mr Slotnik said.
In closing, the participants were asked what one thing in oncology can be done to foster economic reform. "We have to eliminate care that does not add value. Otherwise, we are going to be forced to allocate funds as a result of financial collapse," Dr Newcomer suggested.
Last modified: August 30, 2021