Healthcare Reform Brings Ethical Challenges for Oncologists

Roxanne Nelson

June 13, 2012

June 13, 2012 (Chicago, Illinois) — The Affordable Care Act (ACA), which was passed by Congress and signed into law by President Obama in 2010, has generated a great deal of controversy and debate.

One of the issues raised by the ACA that will affect oncologists is the potential conflict between the cost and value of cancer care for individual patients.

This was discussed here at the 2012 Annual Meeting of the American Society of Clinical Oncology (ASCO) during an education session that examined the ethical challenges of healthcare reform for providers.

Beverley Moy, MD, MPH, clinical director of the breast oncology program at the Massachusetts General Hospital in Boston, outlined the current situation.

Although the bill was signed into law more than 2 years ago, "it is impossible to discuss the ACA without mentioning that it is currently in legal limbo," Dr. Moy noted. The ACA is currently before the Supreme Court; among the central issues of the court case is the constitutionality of the individual mandate.

The oncology community has to brace itself for the changes.

She raised questions related to the court case: If the individual mandate is found to be unconstitutional, is the rest of the law also unconstitutional? Are states being coerced to expand their share of Medicaid costs by being faced with the risk of losing federal funding if they refuse?

The Supreme Court is expected to make a decision later this month. "Regardless of the decision, healthcare reform has set a ball rolling on Capitol Hill that's irreversible," Dr. Moy explained. "The oncology community has to brace itself for the changes and explore the ethical challenges that are inevitable."

Individual vs Society

Jeffrey Peppercorn, MD, MPH, associate professor of medicine at Duke University in Durham, North Carolina, agrees that oncologists will face changes regardless of the decision. The challenge will be whether we can "advocate for our patients' interests and preferences and balance this with wise and efficient use of resources," he said. "I think that's where the clinical and ethical challenges will arise."

In his talk, Dr. Peppercorn noted the dilemma between the economic- and ethics-based viewpoint. "In economics, we're taught to think about what is the most efficient way to deliver goods and services in society," he said. "But in ethics, we're asking what is a just, moral, good, or virtuous society, and how our actions reflect our goals and views of a just society."

In oncology, access to care, health disparities, challenges in communication and decision making, the relation between research and care, drug shortages, and healthcare costs all present challenges with ethical dimensions.

Many of the challenges that physicians and others are grappling with are related to costs. The major goals of healthcare reform were to control costs and improve access. "There is a lot of anxiety on all levels — from the political down to the clinical," said Dr. Peppercorn. "Have we really achieved both of those with this law? If not, what are the pressures that are going to be brought to bear?"

Dr. Peppercorn asked a number of questions related to cost: How will controlling healthcare costs affect care in the clinic? How is "value" defined? What is the appropriate use of resources for individualized care in patients with complex problems?

Devil Is in the Details

"Ultimately, the devil is in the details," he said. We don't know whether healthcare reform will "magnify or ameliorate the current challenges" or whether they will increase or decrease total resources in the healthcare system or per patient, he explained.

The worry that many of us have is that we are going to be asked to do more with less.

"The worry that many of us have is that we are going to be asked to do more with less," he added.

Dr. Peppercorn also asked whether better care can be provide at a lower cost. There is some evidence that this can be done, although it is quite limited at this stage. In a study published in the Journal of Oncology Practice (2010;6:12-18), the cost-effectiveness of a program designed to ensure the delivery of evidence-based care was evaluated in patients with nonsmall-cell lung cancer treated in the outpatient community setting.

Those researchers found that costs substantially decreased with evidence-based care, "from roughly $28,000 in 12 months to $18,000, and there was no difference in survival," said Dr. Peppercorn. "We need more evidence like this to gain greater confidence and...to find out where we can achieve these savings," he added.

Dr. Peppercorn noted that weighing competing allegiances to patients' medical needs against the monetary cost to society is not a new concept. In 1993, Marcia Angell, MD, former editor in chief of the New England Journal of Medicine, wrote that American doctors have to serve as "double agents" — they are asked to practice with one eye on costs and the other on the commitment to their patients (Kennedy Inst Ethics J. 1993;3:279-286).

"Doing so serves a largely political agenda and endangers the patient-centered ethic that is central to medicine," she wrote.

Set a Higher Bar; Use What Works

During the discussion part of the session, expert panelists gave their input on several pressing issues. One of the predominant ethical challenges facing oncologists is how to act in the interest of their patients and of society.

"The ACA and the bundled-payment models catalyze oncologists to become more critical about the quality and quantity of care that we provide," said Dr. Moy, adding that oncologists are going to have to become more aware of evidence-based medicine and guidelines.

Physicians need to step up to the plate, she explained. "As our hospitals, institutions, and cancer centers negotiate the bundle, physicians really have to advocate for themselves to have a seat at the table," she said. "My concern is that as these things are negotiated, there aren't going to be practicing physicians to advise on these issues."

Lee Newcomer, MD, MHA, senior vice president of oncology, genetics, and women's health at UnitedHealthcare, explained that "the interest of the patient and the payer are usually aligned."

He noted that everyone benefits from having care for which there is no evidence "go away." He added that "any treatment, test, or other technology without evidence of effectiveness wastes resources.... The patient loses their time and is exposed to potential harm from side effects or false positives. What needs to be done more are things for which there is evidence."

He acknowledged that it is easy to talk about what isn't evidence-based care, but much harder to stop doing it.

"The profession must set higher a standard for evidence," Dr. Newcomer said. "For example, we should not be wasting time with single-source abstracts or small incremental response rates."

Dr. Newcomer pointed out that he doesn't see anyone objecting to the next trastuzumab — "that isn't how American society works, and I don't see that changing," he said. But there is a sense of urgency to this discussion — "we are out of time."

We have to set a higher bar and not call something better until it really is.

He noted that there is literally no more time to waste. New ideas will need to be tried simultaneously; there will probably be some failures, "but we can't sit and talk anymore — we have to do," Dr. Newcomer emphasized.

Part of doing is deciding where the threshold is for what is good and what is truly better. "A 1% difference isn't going to cut it anymore. We have to set a higher bar and not call something better until it really is," he added.

Practices Evolving and Changing

Daniel M. Hayes, MD, from the Maine Center for Cancer Medicine in Scarborough, said that "nothing is as costly as our current practice of medicine," and there are clearly new ways of doing things.

Practices are changing and evolving. Eventually the current segregation between practice types (such as private practice, academic practice) will be eliminated. "All practices are going to be seeing cancer patients; all practices are going to be seeing higher volumes and expecting to do more with less resources," he explained.

"The resources that are going to be required will have to meet standards that are already set — evidence-based medicine, cost priorities, patient autonomy priorities and, of course, the pressure of improvement in our scientific world," Dr. Hayes said.

He explained that the current world consists of electronic records, nonphysician providers, and patient navigators. He believes that the critical innovations are already in place. Dr. Hayes called on ASCO to help all practices of clinical oncology — medical, surgical, and radiation — "to use some of the tools that will allow these trends and increasing costs to be met personally, professionally, and societally" in an integrated fashion.

2012 Annual Meeting of the American Society of Clinical Oncology. Presented June 2, 2012.

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