The drumbeat is growing among prominent, thoughtful cancer physicians to the effect that they are not only concerned about the costs of the care they give, but that they must be more active in reducing those costs. I know at least some of the publicly-quoted doctors personally, and while I don’t know for sure the details of where they stand, for example, on physician-assisted suicide, I know that they are concerned about taking care of people with cancer, helping them get better or limiting the effects of their illness, and getting new and better ways to treat them. In other words, and to be admittedly crass about it, they can’t be accused of being “death panel” types. These are good doctors.
Some of the recent mail:
- My ASCO Post (newsletter from the American Society of Clinical Oncology) reports that senior doctors at Memorial Sloan-Kettering will not prescribe a certain new treatment for colon cancer that is intended to be an improvement on Roche’s Avastin—at twice the price—but is little or no better, based on the data. These doctors wrote a New York Times op-ed to that effect—after which, the ASCO Post says, the manufacturer cut the price of the new drug in half;
- I open my email to several MedScape Top 10 oncology stories, and one of them is, “Physicians ‘Hit the Barricades’ over Cancer Costs.” Read it, and concerns are raised about the high cost of today’s new, cutting-edge drugs, with a particular disgust for those that simply don’t work very well. But as worrisome to the doctors here is how much money is spent on highfalutin’ scans, like PET scans, to watch for cancers to recur, when there is no evidence that a close surveillance strategy helps, or when there might even be reasonably clear evidence that it doesn’t. The word “rationing” gets used, but drill down on that, and what is really being discussed is a combination of push-back on pharmaceutical industry pricing plus a concern about prioritizing payments for treatments and practices that work the best.
- But look at the next two headlines and one sees:
- “New ALK inhibitor ‘Fantastically Active’”—new drugs designed to treat the 5% of people with lung cancer whose tumors have a particular genetic abnormality work very well for them, probably at high cost once the drugs are launched; and
- “How Insurance Exchanges Will Affect Doctors’ Incomes,” in which we learn that oncology practices may be forced, under the terms of the Affordable Care Act when implemented, to take on an unlimited number of patients whose insurance—and payments under that—are reminiscent of the low rates that prevail for Medicaid. And there’s not much doctors can do about that.
So, I think some of the directions we are going are getting clearer:
- There will be some active price negotiation/price setting, similar to the current regimes in continental Europe or the U.K., to limit the prices of some new drugs. As free-market oriented as I am, I have to admit that I am coming to see this as desirable as well as necessary.
- Also, marginally effective drugs will lose pricing power. In accordance with what I have written on this blog in the past, amen to that when it happens.
- This may affect the availability of some of these, as well as the amount of effort spent on finding new treatments in the first place. That may not be as bad as one might think, but the trip may be bumpy.
- Efforts—led, I hope, by doctors taking care of patients—will continue to define ‘best practices’ and thereby limit at least some ineffective or inefficient practices. Even then, the experts will wrangle about what the data mean and what conclusions to draw.
- Those efficiencies will not be enough to keep overall costs down, and there may well be a strongly perceived need, fairly soon (10 years or so) frankly to deny some effective treatments to some people, solely on cost. For example, the same ASCO Post reports that there may be some drug regimens that prolong life for people with lung cancer who generally are too sick to benefit from chemotherapy and who, by the emerging conventional wisdom, should not receive chemotherapy at all.
- Some, perhaps many, middle-class people who are currently willing and able to pay a bit more for insurance that gives them a choice of which doctor to see or which clinic or hospital to go to, may lose that option as insurers drop those coverages and more people are in practice “nudged” into “Medicaid for all” type exchanges that limit the hospitals you may visit and the doctors you may see. Some of the “best” academic centers and doctors may, I read, be excluded from those exchanges. Does that violate the principle of justice? I would argue that it unjustly limits autonomy (to hedge my Belmontian bets), but if everyone (or almost everyone) is in the same boat, how can anyone cry, “unfair?” But maybe that’s a policy matter, not an ethical one, and maybe the fans of the British NHS are essentially correct. Or not.