Philip Nivatpumin, M.D.

 

 

by Philip Nivatpumin, MD
Medical Director, Patricia D. and M. Scot Kaufman Cancer Center at University of Maryland Upper Chesapeake Medical Center

The last several decades have brought enormous progress in the fight against cancer. Advances in tobacco cessation, genomic sequencing, stereotactic radiotherapy, high resolution imaging, minimally invasive surgery and targeted pharmaceuticals have combined to improve the cancer death rate in the United States by 25 percent since 1991, resulting in 2 million fewer cancer deaths per year [1]. However, this accomplishment comes at an ever increasing financial cost to patients and the nation.  The Institute of Medicine estimates that the yearly direct cost of cancer care in the US will rise from $72 billion in 2004 to $173 billion in 2020, outstripping the rate of cost inflation of other medical services [2]. Cancer care is inherently expensive, with some chemotherapy drug regimens costing over $100,000 per year.  With a growing number of insurance plans “cost-sharing” with patients, the financial burden to cancer patients and their families has never been greater.  Moreover, many health systems and physician networks are also straining under the financial weight of cancer care, struggling to do expensive upgrades in technology and maintain access to state-of-the art treatments for underinsured and uninsured patients.

Dr. S. Yousuf Zafar, a medical oncologist and health policy researcher at Duke University who coined the term “financial toxicity” of cancer care, discusses this growing challenge our society faces in a recent article in the Journal of the National Cancer Institute [3]. The author cites evidence that one in three Americans experience financial hardship as a result of medical expenses. The burden in cancer care is even higher, with upwards of fifty percent of Medicare beneficiaries with cancer paying at least 10% of their income towards out-of-pocket expenses. In the nonelderly, over 10% of cancer patients spend at least 20% of their income on out-of-pocket expenses.  He goes on to cite the economic and personal toll on patients of medical debt. Data from Washington state show that merely having a cancer diagnosis increased the likelihood of declaring personal bankruptcy by 2.65 times.  Furthermore, the cancer patients that declared bankruptcy had a 79% increased mortality than those who had not.  Potential reasons for worse clinical outcomes in financially burdened patients include: patient stress and decreased subjective well-being, a known association between poverty and other poor mental and physical health comorbidities, and actual poorer clinical quality of care due to nonadherence to treatment and limitation of treatment options. Clearly, this is a question not only of health outcomes, but also of social justice and economic inequality in our country. Definitive long term solutions, including policies directed at manufacturers and payers of health care and pharmaceuticals, remain elusive in our current political environment. Dr. Zafar concludes with a call to action by doctors and patients now. Oncologists should select the most effective and lowest cost treatments for their patients, including price transparency and shared decision-making in their offices and exam rooms. Formularies should proactively limit exorbitantly expensive treatments with minimal additional benefit. Finally, just as oncologists must no longer shy away from a discussion with patients about the costs of care, patients must also improve their own health literacy and demand more access to information about the personal impact of their treatments. 

In 2013 the state of Maryland, in conjunction with the Centers for Medicare and Medicaid Services, revised its All-Payer Model to be the first in the nation to initiate statewide global budgeting for hospitals [4]. The purpose of this is simple: to shift from the prior fee-for-service volume based reimbursement to an emphasis on “value.” Value was defined as appropriate clinical care, with a measurable reduction in unnecessary readmissions and avoidable complications of care.  As a result of the Maryland law and the nationwide crisis in the cost of cancer care delivery, the University of Maryland Cancer Network has actively embraced the goals of cancer cost containment for both the individual patient and the larger health system. As applied to the delivery of cancer care, this has resulted in a University of Maryland system-wide emphasis on:

  1. the best, most advanced and clinically effective care for our patients,
  2. a greater emphasis on patient “navigation” by nurses, social workers, dieticians and rehabilitation specialists to reduce complications, emergency room visits and hospital admissions, 
  3. greater financial assistance and transparency for patients, in the form of financial assistance programs and counseling and 
  4. early initiation of palliative care and “bridge” programs for patients with incurable cancers, so they can maximize quality of life and minimize painful, unnecessary deaths in the hospital.

An example of this is at the University of Maryland Upper Chesapeake’s Kaufman Cancer Center where every month, a group of doctors, nurses, social workers, administrators, pharmacists, financial counselors and patient advocates meet to discuss both the clinical and financial needs of our patients.  The best, most cost-effective regimens are chosen and updated continuously.  Patient assistance programs are identified and communicated through all parts of the cancer center.  Patient outcomes data are reviewed to insure we are delivering the not only the best care, but that we are minimizing the burdens on our patients as much as possible.  Finally, patient feedback and response is actively sought after to ensure that we are always providing just, transparent and satisfying care.  At a broader level, leaders at the University of Maryland Greenebaum Comprehensive Cancer Center have brought the issue of financial toxicity of cancer care to the state and national level, in the hopes of enacting broader health policies aimed at value-based care.  In the coming year, we hope to improve on several fronts including: measuring and improving the quality of our cancer services, greater price transparency for patients, reducing unnecessary cancer related complications and hospitalizations, and a system-wide standardization of most efficient practices.

References

  1. Cancer Statistics, 2017. Published early online January 5, 2017 in CA Cancer Journal for Clinicians. First author Rebecca L. Siegel, MPH, American Cancer Society, Atlanta, Ga.
  2. Institute of Medicine, 2013. Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis. Washington, DC: The National Academies Press.
  3. Zafar, SY. "Financial Toxicity of Cancer Care: It's Time to Intervene." Journal of the National Cancer Institute 108, no. 5 (May 2016).
  4. Patel A. et al. Maryland’s Global Hospital Budgets – Preliminary Results from an All-Payer Model. N Engl J Med 2015; 373:1899-1901November 12, 2015