Editor's Note: In March, the American Society of Clinical Oncology (ASCO) released a report, "The State of Cancer Care in America: 2014," that served as a clarion call for the oncology community.
Citing a rising demand for oncologists' services, an aging workforce, and high levels of burnout among oncologists, the report predicted that there would be a shortage of more than 1400 oncologists by 2025.
The report also highlighted the high cost of cancer drugs and downward pressure on Medicare reimbursement levels, issues that were also included in a 2013 report by the Association of Community Cancer Centers (ACCC).
Taken together, the two reports outline a series of threats to the way cancer care is currently being delivered in the United States. In a series of interviews on the potential impact of these threats, Medscape spoke with Peter P. Yu, MD, ASCO's current president and Director of Cancer Research at the Palo Alto Medical Foundation in Palo Alto, California; Jennie Crews, MD, ACCC treasurer and Director of Cancer Services at PeaceHealth St. Joseph Medical Center in Bellingham, Washington; and Matthew Farber, Director of Provider Economics & Public Policy for ACCC in Rockville, Maryland.
Unless cited otherwise, the background facts presented throughout were drawn from these two reports.
High Cost of Treatment
• Overall, one quarter of uninsured individuals forego care because of cost.
• While costs are rising throughout the healthcare system, the trend is especially pronounced in cancer care; annual costs are projected to rise from $104 billion in 2006 to more than $173 billion in 2020.
• The annual excess economic burden of survivorship among recently diagnosed cancer survivors is more than $16,000 per survivor, and among those previously diagnosed, it is more than $4000 per year.
Dr. Yu: We repeatedly hear that 25% of personal bankruptcies are precipitated by a healthcare crisis. And the crisis of being diagnosed with cancer is one of the more common precipitants of that situation. Even if patients are not going bankrupt, they are still being faced with significant personal responsibility for the bill. And as the costs of drugs are escalating, it's a good news/bad news situation: As we get more and more new drugs increasing our patients' longevity, it's improving their prognosis, but it comes with a very high price tag.
Twenty percent of a $10,000 drug bill is prohibitive for many patients. If you look at a medication like Gleevec (imatinib) -- which is probably the poster child of a modern-day targeted therapy -- it's a relatively low-toxicity treatment, it's an oral agent, and the responses are durable and often complete. It has extended longevity for years, and probably for decades for patients with chronic myelogenous leukemia. They do not need to go through all of the risks of an allogeneic transplant. This is a medication that by any measure would be considered a high-value medication. And yet we hear that patients are not taking this medication, or maybe are taking it every other day instead of every day, simply because they can't afford it.
Dr. Crews: We've been very fortunate in that Washington State was one of the states that expanded the Medicaid programs, so we've had a decrease in the number of uninsured patients. But the problems that we're seeing now relate to patients who have high copays and a very difficult time meeting out-of-pocket expenses for their drugs. It's interesting because in conversations with patients, they don't often voluntarily tell physicians that they're having financial issues. I think they are concerned about wanting to please the doctor, wanting to do what the doctor recommends, so I think they're sometimes hesitant to bring that up. I have had patients tell me that they're able to make ends meet right now, but they're not sure how long they'll be able to sustain that.
Mr. Farber: There are other sides, too, that weigh on the providers. When you have patients who can't afford their medications, there are times when the providers are paying for them. If it is an injected therapy, they are paying for the therapy and then waiting to get reimbursed from the insurer and from the patient's copay responsibility. And if there is nonpayment, for some reason, it might fall onto the backs of providers trying to get recouped for those costs. In addition, just the high cost of stocking these drugs in the pharmacies and in the offices can be incredibly high. There has been a significant shift over the past 10 years of how much money these practices have to spend on the front end to buy the drugs in the first place, with the assumption that once the drugs are given to the patients, all [the practice] will be made whole on the back end by, again, the payment from the insurer and from the patient.
So let's assume that those payments do come in. They don't always come in in a timely manner, either. We do know that there are a lot of cases, especially with these high-cost drugs, of significant delays that happen in reimbursement, whether it is just long turnaround time for claims or insurers who are denying the first round and then only paying out on appeal. That can be very difficult from a cashflow perspective on the practice. Those are some of the issues that we're having. Ten years ago, practices didn't have nearly as high a drug spend as they do now, and the high cost of drugs is a significant part of that. Now, at the same time, another part of that is the huge explosion in the number of treatments that we have had and have gotten approved recently, which is certainly wonderful. But it has that other side effect on many [community oncology practices] as well.
Medscape Oncology © 2014
Cite this: 7 Threats to Cancer Care - Medscape - Sep 10, 2014.