Continental Divide? The attitudes of US and Canadian oncologists on the costs, cost-effectiveness, and health policies associated with new cancer drugs

National survey of patient perspectives on cost discussions among recipients of copay assistance

BACKGROUND

Individuals with cancer and other medical conditions often experience financial concerns from high costs-of-care and may utilize copay assistance programs (CAP). We sought to describe CAP recipients' experiences/preferences for cost discussions with clinicians.

METHODS

We conducted a national, cross-sectional electronic-survey from 10/2022 to 11/2022 of CAP recipients with cancer or autoimmune conditions to assess patient perspectives on cost discussions. We used multivariable logistic regression models to explore associations of patient perspectives on cost discussions with patient characteristics and patient-reported outcomes (eg, financial toxicity, depression/anxiety, and health literacy).

RESULTS

Among 1,566 participants, 71% had cancer and 29% had autoimmune conditions. Although 62% of respondents desired cost discussions, only 32% reported discussions took place. Additionally, 52% of respondents wanted their doctor to consider out-of-pocket costs when deciding the best treatment, and 61% of respondents felt doctors should ensure patients can afford treatment prescribed. Participants with depression symptoms were more likely to want doctors to consider out-of-pocket costs (OR = 1.54, P = .005) and to believe doctors should ensure patients can afford treatment (OR = 1.60, P = .005). Those with severe financial toxicity were more likely to desire cost discussions (OR = 1.65, P < .001) and want doctors to consider out-of-pocket costs (OR = 1.52, P = .001). Participants with marginal/inadequate health literacy were more likely to desire cost discussions (OR = 1.37, P = .01) and believe doctors should ensure patients can afford treatment (OR = 1.30, P = .036).

CONCLUSIONS

In this large sample of CAP recipients with cancer and autoimmune conditions, most reported a desire for cost discussions, but under one-third reported such discussions took place.

Demand for and Occurrence of Medication Cost Conversations: A Narrative Review

High medication prices can create a financial burden for patients and reduce medication initiation. To improve decision making, public policy is supporting development of tools to provide real-time prescription drug prices. We reviewed the literature on medication cost conversations to characterize the context in which these tools may be used. Our review included 42 articles: a median of 84% of patients across four clinical specialties reported a desire for cost conversations (n = 7 articles) but only 23% reported having held a cost conversation across six specialties (n = 16 articles). Non-White and older patients were less likely to report having held a cost conversation than White and younger patients in 9 of 13 and 5 of 9 articles, respectively, examining these associations. Our review indicates that tools providing price information may not result in improved decision making without complementary interventions that increase the frequency of cost conversations with a focus on protected groups.

Recommending Unfunded Innovative Cancer Therapies: Ethical vs. Clinical Perspectives among Oncologists on a Public Healthcare System-A Mixed-Methods Study

Over the past decade, there has been a growing development of innovative technologies to treat cancer. Many of these technologies are expensive and not funded by health funds. The present study examined physicians' perceptions of the ethical and clinical aspects of the recommendation and use of unfunded technologies for cancer treatment. This mixed-methods study surveyed 127 oncologists regarding their perceptions toward using unfunded innovative cancer treatment technologies, followed by in-depth interviews with 16 oncologists. Most respondents believed that patients should be offered all treatment alternatives, regardless of their financial situation. However, 59% indicated that they often face dilemmas regarding recommending new unfunded treatments to patients with financial difficulties and without private health insurance. Over a third (38%) stated that they felt uncomfortable discussing the cost of treatment with patients. A predictive model found that physicians facing patients whose medical condition worsened due to an inability to access new treatments, and who expressed the opinion that physicians can assist in locating funding for patients who cannot afford treatments, were more likely to recommend unfunded innovative therapies to patients (F = 5.22, R2 = 0.15, p < 0.001). Subsequent in-depth interviews revealed four key themes: economic considerations in choosing therapy, patient-physician communication, the public healthcare fund, and discussion of treatment costs. Physicians feel a professional commitment to offer patients the best medical care and a moral duty to discuss costs and minimize patients' financial difficulty. There is a need for careful and balanced use of innovative life-prolonging technologies while putting patients at the center of discourse on this complex and controversial issue. It is essential to develop a psychosocial support program for physicians and patients dealing with ethical and psychosocial dilemmas and to set guidelines for oncologists to conduct a comprehensive and collaborative physician-patient discourse regarding all aspects of treatment.

Benefits of High-Volume Medical Oncology Care for Noncurable Pancreatic Adenocarcinoma: A Population-Based Analysis

BACKGROUND

Although pancreatic adenocarcinoma (PA) surgery performed by high-volume (HV) providers yields better outcomes, volume-outcome relationships are unknown for medical oncologists. This study examined variation in practice and outcomes in noncurative management of PA based on medical oncology provider volume.

METHODS

This population-based cohort study linked administrative healthcare datasets and included nonresected PA from 2005 through 2016. The volume of PA consultations per medical oncology provider per year was divided into quintiles, with HV providers (≥16 patients/year) constituting the fifth quintile and low-volume (LV) providers the first to fourth quintiles. Outcomes were receipt of chemotherapy and overall survival (OS). The Brown-Forsythe-Levene (BFL) test for equality of variances was performed to assess outcome variability between provider-volume quintiles. Multivariate regression models were used to examine the association between management by HV provider and outcomes.

RESULTS

A total of 7,062 patients with noncurable PA consulted with medical oncology providers. Variability was seen in receipt of chemotherapy and median survival based on provider volume (BFL, P<.001 for both), with superior 1-year OS for HV providers (30.1%; 95% CI, 27.7%-32.4%) compared with LV providers (19.7%; 95% CI, 18.5%-20.6%) (P<.001). After adjustment for age at diagnosis, sex, comorbidity burden, rural residence, income, and diagnosis period, HV provider care was independently associated with higher odds of receiving chemotherapy (odds ratio, 1.19; 95% CI, 1.05-1.34) and with superior OS (hazard ratio, 0.79; 95% CI, 0.74-0.84).

CONCLUSIONS

Significant variation was seen in noncurative management and outcomes of PA based on provider volume, with management by an HV provider being independently associated with superior OS and higher odds of receiving chemotherapy. This information is important to inform disease care pathways and care organization. Cancer care systems could consider increasing the number of HV providers to reduce variation and improve outcomes.

Defining the clinician's role in mitigating financial toxicity: an exploratory study

BACKGROUND

Financial toxicity describes the financial burden imposed onto patients by a cancer diagnosis and is a growing concern. Many clinicians do not currently address financial toxicity despite patients' desire for them to do so. Current literature explores physicians' perspectives but does not clearly define an actionable role clinicians can take to address financial toxicity. We sought to fill this gap by first assessing clinicians' perspective on their role in alleviating financial toxicity at our institution. We subsequently aimed to identify current barriers to mitigating financial toxicity and to garner feedback on clinician-oriented interventions to address this growing problem.

METHODS

We developed an 18-item electronic, anonymous survey through Redcap. We invited all oncology clinicians including attending physicians, advance practice providers, and trainees at our institution to participate.

RESULTS

A total of 72 clinicians (30%) completed the survey. The majority agreed that clinicians have a role in addressing cost. The top three barriers to discussing cost with patients were knowledge of out of pocket costs, time, and awareness of resources. Less than half of respondents used an existing comparative cost tool to incorporate cost consciousness into treatment decisions. The most desired intervention was an institutional resource guide. In open-ended comments, the most common barrier described was transparency of out of pocket costs, and the most common solution proposed was a multi-disciplinary approach to addressing financial concerns patient face.

DISCUSSION

Improving price transparency, incorporating existing resources into clinical practice, and streamlining multi-disciplinary support may help overcome barriers to addressing financial toxicity.

Economic impacts of care by high-volume providers for non-curative esophagogastric cancer: a population-based analysis

BACKGROUND

Esophagogastric cancer (EGC) is one of the deadliest and costliest malignancies to treat. Care by high-volume providers can provide better outcomes for patients with EGC. Cost implications of volume-based cancer care are unclear. We examined the cost-effectiveness of care by high-volume medical oncology providers for non-curative management of EGC.

METHODS

We conducted a population-based cohort study of non-curative EGC over 2005-2017 by linking administrative datasets. High-volume was defined as ≥ 11 patients/provider/year. Healthcare costs ($USD/patient/month-survived) were computed from diagnosis to death or end of follow-up from the perspective of the healthcare system. Multivariable quantile regression examined the association between care by high-volume providers and costs. Sensitivity analyses were conducted by varying costing horizons and high-volume definitions.

RESULTS

Among 7011 non-curative EGC patients, median overall survival was superior with care by high-volume providers with 7.0 (IQR 3.3-13.3) compared to 5.9 (IQR 2.6-12.1) months (p < 0.001) for low-volume providers. Median costs/patient/month-lived were lower for high-volume providers ($5518 vs. $5911; p < 0.001), owing to lower inpatient acute care costs, despite higher medication-associated and radiotherapy costs. Care by high-volume providers was independently associated with a reduction of $599 per patient/month-lived (95% confidence interval - 966 to - 331) compared to low-volume providers. The incremental cost-effectiveness ratio was - 393. Care by high-volume providers remained the dominant strategy when varying the costing horizon and the high-volume definition.

CONCLUSION

Care by high-volume providers for non-curative EGC is associated with superior survival and lower healthcare costs, indicating a dominant strategy that may provide an opportunity to improve cost-effectiveness of care delivery.

Expert-Based Strategies to Improve Access to Cancer Therapeutics at the Hospital Level

Background: Challenges related to access to cancer medications is an increasing global problem that has far-reaching impact on patients and healthcare systems. In this article, we are enlisting suggested solutions at the hospital or practice level to maximize the access to these important treatment modalities. Methods: An expert panel of practicing oncologists, clinical pharmacists, and health economists convened using a framework approach. The panelists identified individuals and entities that impact the use of cancer therapeutics and how they can improve the utilization and access to them. They enlisted the potential actions that hospital management and staff can take to enhance access to cancer therapeutics, then they grouped them into specific categories. Results: List of potential strategies and related action items were compiled into different categories including hospital leadership, drug evaluation entities, pharmacy, physicians, patients and families, and other parties. Recommendations included various actions to be considered by each group to achieve set goals. Conclusion: Our expert panel recommend multiple strategies and approaches to reduce the cost of cancer medications and improve patients' access to them. These recommendations can be adapted by the decision-makers and staff of the hospitals to their own settings and the current circumstances.

Cost health literacy as a physician skill-set: the relationship between oncologist reported knowledge and engagement with patients on financial toxicity

INTRODUCTION

Oncologists are increasingly encouraged to communicate with patients about cost; however, they may lack the cost health literacy required to effectively perform this task.

METHODS

We conducted a pilot survey of oncologists in an academic medical center to assess potential factors that may influence provider attitudes and practices related to financial toxicity. We assessed perceived provider knowledge of treatment costs, insurance coverage and co-pays, and financially focused resources. We then evaluated the relationship between perceived knowledge and reported engagement with issues of financial toxicity.

RESULTS

Of 45 respondents (85% response rate), 58% had changed treatment within the past year as a result of patient financial burden. On self-report, 36% discussed out-of-pocket costs with patients, 42% assessed patient financial distress, but only 20% felt they could intervene upon financial toxicity. Self-perceived awareness of cost health literacy concepts were low; only 16% reporting high out-of-pocket cost knowledge, 31-33% high insurance knowledge, and 8% high awareness of financial resources. Report of cost discussion was associated with greater perceived awareness of both out-of-pocket costs and insurance design. However, reported financial distress assessment was only associated with perceived insurance awareness, not perceived cost knowledge. Cost health literacy was not associated with an increased sense of being able to impact on financial toxicity.

CONCLUSION

Oncologists acknowledge deficits in knowledge and skills that may play a role in the discussion and management of financial toxicity. Some cost health literacy competencies appear to correlate with physician involvement with financial toxicity, suggesting that education on this topic may facilitate physician engagement.

Variation in receipt of therapy and survival with provider volume for medical oncology in non-curative esophago-gastric cancer: a population-based analysis

BACKGROUND

While surgical care by high-volume providers for esophago-gastric cancer (EGC) yields better outcomes, volume-outcome relationships are unknown for systemic therapy. We examined receipt of therapy and outcomes in the non-curative management of EGC based on medical oncology provider volume.

METHODS

We conducted a population based retrospective cohort study of non-curative EGC over 2005-2017 by linking administrative healthcare datasets. The volume of new EGC consultations per medical oncology provider per year was calculated and divided into quintiles. High-volume (HV) medical oncologists were defined as the 4-5th quintiles. Outcomes were receipt of chemotherapy and overall survival (OS). Multivariate logistic and Cox-proportional hazards regressions examined the association between management by HV medical oncologist, receipt of systemic therapy, and OS.

RESULTS

7011 EGC patients with non-curative management consulted with medical oncology. 1-year OS was superior for HV medical oncologists (> 11 patients/year), with 28.4% (95% CI 26.7-30.2%) compared to 25.1% (95% CI 23.8-26.3%) for low volume (p < 0.001). After adjusting for age, sex, comorbidity burden, rurality, income quintile, and diagnosis year, HV medical oncologist was independently associated with higher odds of receiving chemotherapy (OR 1.13, 95% CI 1.01-1.26), and independently associated with superior OS (HR 0.89, 95% CI 0.84-0.93).

CONCLUSIONS

Medical oncology provider volume was associated with variation in non-curative management and outcomes of EGC. Care by an HV medical oncologist was independently associated with higher odds of receiving chemotherapy and superior OS, after adjusting for case mix. This information is important to inform disease care pathways and care organization; an increase in the number of HV medical oncologists may reduce variation and improve outcomes.

The cost-effectiveness of mammography-based female breast cancer screening in Canadian populations: a systematic review.. [DOI: 10.1101/2020.01.18.20018044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

Introduction

Mammography-based breast cancer screening is an important aspect of female breast cancer prevention within the Canadian healthcare system. The current literature on female breast cancer screening is largely focused on the health outcomes that result from screening. There is comparatively little data on the cost-effectiveness of the screening. Therefore, this paper sought to conduct a systematic review of the literature on the cost effectiveness of mammography-based breast cancer screening within female Canadian populations.

Materials and methods

A systematic review was performed in the PubMed database to identify all studies published within the last 10 years that addressed breast cancer screening and evaluate cost-effectiveness in a Canadian population.

Results

The search yielded five studies for inclusion, only three of which were applicable to average-risk Canadian women. The benefits of mortality reduction rose approximately linearly with costs, while costs were linearly dependent on the number of lifetime screens per woman. Moreover, triennial screening for average-risk women aged 50-69 years was found to be the most cost-effective in terms of cost per quality adjusted life year. The use of MRI in conjunction with mammography for women with the BRCA 1/2 mutation was found to be cost-effective while annual mammography-based screening for women with dense breasts was found to be cost-ineffective.

Conclusion

In spite of the growing interest to enhance breast cancer screening programs, analyses of the cost-effectiveness of mammography-based screening within Canadian populations are scarcely reported and have heterogeneous methodologies. The existing data suggests that Canada’s current breast cancer screening policy to screen average-risk women aged 50-74, biennially or triennially is cost-effective. These findings could be of interest to health policy makers when making decisions regarding resource allocation; however, further studies in this field are required in order to make stronger recommendations regarding cost-effectiveness.

Conversations About Financial Issues in Routine Oncology Practices: A Multicenter Study

PURPOSE

To describe the frequency, content, dynamics, and patterns of cost conversations in academic medical oncology across tumor types.

PATIENTS AND METHODS

We reviewed 529 audio recordings between May 3, 2012, to September 23, 2014, from a prospective three-site communication study in which patients at any stage of management for any solid tumor malignancy were seen in routine oncology appointments. Recordings were deidentified, transcribed, and flagged for any mention of cost. We coded encounters and used qualitative thematic analysis.

RESULTS

Financial issues were discussed in 151 (28%) of 529 recordings. Conversations lasted shorter than 2 minutes on average. Patients/caregivers raised a majority of discussions (106 of 151), and 40% of cost concerns raised by patients/caregivers were not verbally acknowledged by clinicians. Social service referrals were made only six times. Themes from content analysis were related to insurance eligibility/process, work insecurity, cost of drugs, cost used as tool to influence medical decision making, health care-specific costs, and basic needs. Financial concerns influenced oncology work processes via test or medication coverage denials, creating paperwork for clinicians, potentially influencing patient involvement in trials, and leading to medication self-rationing or similar behaviors. Typically, financial concerns were associated with negative emotions.

CONCLUSION

Financial issues were raised in approximately one in four academic oncology visits. These brief conversations were usually initiated by patients/caregivers, went frequently unaddressed by clinicians, and seemed to influence medical decision making and work processes and contribute to distress. Themes identified shed light on the kinds of gaps that must be addressed to help patients with cancer cope with the rising cost of care.

What Is the Value of Innovative Pharmaceutical Therapies in Oncology and Hematology? A Willingness-to-Pay Study in Bulgaria

OBJECTIVES

To analyze the views of Bulgarian oncologists and hematologists regarding the value of innovative pharmaceutical treatments in their clinical area.

METHODS

Physicians were invited to review a life-prolonging scenario and to indicate what minimum improvement in median survival a new treatment would have to generate for them to recommend it over the standard of care. Respondents were also asked to state the highest cost at which they would recommend a new therapy that would improve patient's health-related quality of life (HRQoL) but would have no impact on survival. In addition, physicians were asked whether they would consider different responses under certain circumstances. Responses were used to calculate incremental cost-effectiveness ratios (ICERs) for each scenario.

RESULTS

In the life-prolonging scenario, participants required a median of 12-month improvement in the survival to reimburse a new therapy at an incremental cost of €50 000, implying a willingness-to-pay of €50 000 per QALY gained. In the HRQoL-enhancing scenario, respondents indicated a €100 000 median cost per QALY gained. We observed a significant variation in responses. Although the median ICER for better HRQoL was twice as high as the median ICER for longer survival, 5% trimmed mean values were almost equal. Physicians did not believe that a higher ICER should be used for the treatment of children or for rare diseases.

CONCLUSIONS

We found a high willingness-to-pay for innovative drugs in oncology and hematology. The wide range of responses observed, however, indirectly implies a lack of consensus on the use of explicit ICER thresholds in Bulgaria.

Clinical impact and cost-effectiveness of a 176-condition expanded carrier screen

PURPOSE

Carrier screening identifies couples at high risk for conceiving offspring affected with serious heritable conditions. Minimal guidelines recommend offering testing for cystic fibrosis and spinal muscular atrophy, but expanded carrier screening (ECS) assesses hundreds of conditions simultaneously. Although medical societies consider ECS an acceptable practice, the health economics of ECS remain incompletely characterized.

METHODS

Preconception screening was modeled using a decision tree comparing minimal screening and a 176-condition ECS panel. Carrier rates from >60,000 patients, primarily with private insurance, informed disease incidence estimates, while cost and life-years-lost data were aggregated from the literature and a cost-of-care database. Model robustness was evaluated using one-way and probabilistic sensitivity analyses.

RESULTS

For every 100,000 pregnancies, 290 are predicted to be affected by ECS-panel conditions, which, on average, increase mortality by 26 undiscounted life-years and individually incur $1,100,000 in lifetime costs. Relative to minimal screening, preconception ECS reduces the affected birth rate and is estimated to be cost-effective (i.e.,<$50,000 incremental cost per life-year), findings robust to perturbation.

CONCLUSION

Based on screened patients predominantly with private coverage, preconception ECS is predicted to reduce the burden of Mendelian disease in a cost-effective manner compared with minimal screening. The data and framework herein may facilitate similar assessments in other cohorts.

Physician attitudes about cost consciousness for breast cancer treatment: differences by cancer sub-specialty

PURPOSE

High costs of cancer care place considerable burden on patients and society. Despite increasing recognition that providers should play a role in reducing care costs, how physicians across cancer specialties differ in their cost-consciousness has not been reported. We examined cost-consciousness regarding breast cancer care among medical oncologists, surgeons, and radiation oncologists.

METHODS

We identified 514 cancer surgeons, 504 medical oncologists, and 251 radiation oncologists by patient report through the iCanCare study. iCanCare identified newly diagnosed women with breast cancer through the Surveillance, Epidemiology, and End Results (SEER) registries of Georgia and Los Angeles. We queried providers on three dimensions of cost-consciousness: (1) perceived importance of cost saving for society, patients, practice, and payers; (2) awareness of patient out-of-pocket expenses; and (3) discussion of financial burden.

RESULTS

We received responses from 376 surgeons (73%), 304 medical oncologists (60%), and 169 radiation oncologists (67%). Overall levels of cost-consciousness were moderate, with scores ranging from 2.5 to 3.0 out of 5. After adjusting for covariates, surgeons had the lowest scores on all three cost-consciousness measures; medical oncologists had the highest scores. Pairwise contrasts showed surgeons had significantly lower scores than medical oncologists for all three measures and significantly lower scores than radiation oncologists for two of the three cost-consciousness variables: importance of cost saving and discussion of financial burden.

CONCLUSIONS

How cost-consciousness impacts medical decision-making across specialty and how policy, structural, and behavioral interventions might sensitize providers regarding cost-related matters merit further examination.

Cost-effectiveness of axicabtagene ciloleucel for adult patients with relapsed or refractory large B-cell lymphoma in the United States

PURPOSE

Axicabtagene ciloleucel (axi-cel) was recently approved for treatment of relapsed or refractory (R/R) large B-cell lymphoma (LBCL) following two or more prior therapies. As the first CAR T-cell therapy available for adults in the US, there are important questions about clinical and economic value. The objective of this study was to assess the cost-effectiveness of axi-cel compared to salvage chemotherapy using a decision model and a US payer perspective.

MATERIALS AND METHODS

A decision model was developed to estimate life years (LYs), quality-adjusted life years (QALYs), and lifetime cost for adult patients with R/R LBCL treated with axi-cel vs salvage chemotherapy (R-DHAP). Patient-level analyses of the ZUMA-1 and SCHOLAR-1 studies were used to inform the model and to estimate the proportion achieving long-term survival. Drug and procedure costs were derived from US average sales prices and Medicare reimbursement schedules. Future healthcare costs in long-term remission was derived from per capita Medicare spending. Utility values were derived from patient-level data from ZUMA-1 and external literature. One-way and probabilistic sensitivity analyses evaluated uncertainty. Outcomes were calculated over a lifetime horizon and were discounted at 3% per year.

RESULTS

In the base case, LYs, QALYs, and lifetime costs were 9.5, 7.7, and $552,921 for axi-cel vs 2.6, 1.1, and $172,737 for salvage chemotherapy, respectively. The axi-cel cost per QALY gained was $58,146. Cost-effectiveness was most sensitive to the fraction achieving long-term remission, discount rate, and axi-cel price. The likelihood that axi-cel is cost-effective was 95% at a willingness to pay of $100,000 per QALY.

CONCLUSION

Axi-cel is a potentially cost-effective alternative to salvage chemotherapy for adults with R/R LBCL. Long-term follow-up is necessary to reduce uncertainties about health outcomes.

Communicating the Financial Burden of Treatment With Patients

In recent years, high health care costs and the financial burden of cancer care have received increased attention. In response to the financial burden of cancer care, patients may jeopardize their health outcomes by not properly adhering to prescribed therapies or even forgoing and delaying care in an effort to defray costs. In addition, the financial burden experienced by patients with cancer may negatively impact clinical outcomes, such as quality of life, physical and psychological symptoms, and potentially, even survival. Notably, in the current era of targeted treatment and immunotherapies for patients with cancer, the rising costs of cancer continue to remain at the forefront of patient concerns. Therefore, a critical need exists to determine how best to assist patients with the cost burden of cancer diagnosis and treatment.

Oncologists' Views on Using Value to Guide Cancer Treatment Decisions

OBJECTIVES

Cancer costs have increased substantially in the past decades, prompting specialty societies to urge oncologists to consider value in clinical decision making. Despite oncologists' crucial role in guiding cancer care, current literature is sparse with respect to the oncologists' views on value. Here, we evaluated oncologists perceptions of the use and measurement of value in cancer care.

METHODS

We conducted in-depth, open-ended interviews with 31 US oncologists practicing nationwide in various environments. Oncologists discussed the definition, measurement, and implementation of value. Transcripts were analyzed using matrix and thematic analysis.

RESULTS

Oncologists' definitions of value varied greatly. Some described versions of the standard health economic definition of value, that is, cost relative to health outcomes. Many others did not include cost in their definition of value. Oncologists considered patient goals and quality of life as important components of value that they perceived were missing from current value measurement. Oncologists prioritized a patient-centric view of value over societal or other perspectives. Oncologists were inclined to consider the value of a treatment only if they perceived treatment would pose a financial burden to patients. Oncologists had differing opinions regarding who should be responsible for determining whether care is low value but generally felt this should remain within the purview of the oncology community.

CONCLUSIONS

Oncologists agreed that cost was an important issue, but disagreed about whether cost was involved in value as well as the role of value in guiding treatment. Better clarity and alignment on the definition of and appropriate way to measure value is critical to the success of efforts to improve value in cancer care.

Medical oncologists' willingness to participate in bundled payment programs

Background

Bundled payment programs play an increasingly important role in transforming reimbursement for oncologic care. We assessed determinants of oncologists’ willingness to participate in bundled payment programs for breast cancer. We hypothesized that providers would be more likely to participate in bundled payment programs if offered higher levels of reimbursement for each episode of care.

Methods

Oncologists from Florida, New Jersey, New York, and Pennsylvania were identified in the AMA database or by patients listed in state cancer registries. Providers were randomized to receive one of four versions of a survey describing bundled payment programs offering different levels of compensation for the first year of localized breast cancer treatment ($5000, $10,000, $15,000, or $20,000). Physicians rated their likelihood of participation in a bundled program on a Likert scale. Logistic regression was used to analyze determinants of likelihood of participation in bundling.

Results

Among 460 respondents, only 17% of oncologists were highly likely to participate in a bundled program paying $5000 for the first year of care, rising to 41% for the $15,000 program, but falling to 34% for the $20,000 program. Likelihood of participation was higher among oncologists who were male, older, and believed that cancer patients should not be offered high-cost drugs with minimal survival benefit.

Conclusion

Our results suggest that medical oncologists have limited enthusiasm for bundled payments, and higher payments may not overcome resistance to bundling among a substantial proportion of physicians.

Cancer cost communication: experiences and preferences of patients, caregivers, and oncologists-a nationwide triad study

PURPOSE

We assessed cost communication between cancer patients, caregivers, and oncologists and identified factors associated with communication concordance.

METHODS

A national, multicenter, cross-sectional survey of patient-caregiver-oncologist triads was performed, and 725 patient-caregiver pairs, recruited by 134 oncologists in 13 cancer centers, were studied. Discordance in preferences and experiences regarding cost communication between patients, caregivers, and oncologists were assessed. Hierarchical generalized linear models were used to identify predictors of concordance and to identity the possible association of concordance with patient satisfaction and degree of trust in the physician.

RESULTS

Although the oncologists thought that patients would be affected by the cost of care, only half of them were aware of the subjective burden experienced by their patients, and the degree of concordance for this parameter was very low (weighted kappa coefficient = 0.06). Caregivers consistently showed similar preferences to those of the patients. After controlling for covariates, the education level of patients [adjusted odds ratio (aOR) for > 12 vs. < 9 years, 2.92; 95% confidence interval (CI), 1.87-4.56], actual out-of-pocket costs [aOR for ≥ 8 million vs. < 2 million Korean Won, 0.56; 95% CI, 0.34-0.89], and physician age (aOR for ≥ 55 vs. < 45 years, 1.83; 95% CI, 1.04-3.21) were significant.

CONCLUSIONS

The results show underestimation by oncologists regarding the subjective financial burden on a patient, and poor patient-physician concordance in cost communication. Oncologists should be more cognizant of patient OOP costs that are not indexed by objective criteria, but instead involve individual patient perceptions.

Cost-effectiveness of mammography from a publicly funded health care system perspective

BACKGROUND

The implementation of population-wide breast cancer screening programs has important budget implications. We evaluated the cost-effectiveness of various breast cancer screening scenarios in Canada from a publicly funded health care system perspective using an established breast cancer simulation model.

METHODS

Breast cancer incidence, outcomes and total health care system costs (screening, investigation, diagnosis and treatment) for the Canadian health care environment were modelled. The model predicted costs (in 2012 dollars), life-years gained and quality-adjusted life-years (QALYs) gained for 11 active screening scenarios that varied by age range for starting and stopping screening (40-74 yr) and frequency of screening (annual, biennial or triennial) relative to no screening. All outcomes were discounted. Marginal and incremental cost-effectiveness analyses were conducted. One-way sensitivity analyses of key parameters assessed robustness.

RESULTS

The lifetime overall costs (undiscounted) to the health care system for annual screening per 1000 women ranged from $7.4 million (for women aged 50-69 yr) to $10.7 million (40-74 yr). For biennial and triennial screening per 1000 women (aged 50-74 yr), costs were less, at about $6.1 million and $5.3 million, respectively. The incremental cost-utility ratio varied from $36 981/QALY for triennial screening in women aged 50-69 versus no screening to $38 142/QALY for biennial screening in those aged 50-69 and $83 845/QALY for annual screening in those aged 40-74.

INTERPRETATION

Our economic analysis showed that both benefits of mortality reduction and costs rose together linearly with the number of lifetime screens per women. The decision on how to screen is related mainly to willingness to pay and additional considerations such as the number of women recalled after a positive screening result.

Economic Analysis of Prostate-Specific Antigen Screening and Selective Treatment Strategies

IMPORTANCE

Prostate-specific antigen (PSA) screening for prostate cancer is controversial. Experts have suggested more personalized or more conservative strategies to improve benefit-risk tradeoffs, but the value of these strategies-particularly when combined with increased conservative management for low-risk cases-is uncertain.

OBJECTIVES

To evaluate the potential cost-effectiveness of plausible PSA screening strategies and to assess the value added by increased use of conservative management among low-risk, screen-detected cases.

DESIGN, SETTING, AND PARTICIPANTS

A microsimulation model of prostate cancer incidence and mortality was created. A simulated contemporary cohort of US men beginning at 40 years of age underwent 18 strategies for PSA screening. Treatment strategies included (1) contemporary treatment practices based on age and cancer stage and grade observed in the Surveillance, Epidemiology, and End Results program in 2010 or (2) selective treatment practices whereby cases with a Gleason score lower than 7 and clinical T2a stage cancer or lower are treated only after clinical progression, and all other cases undergo contemporary treatment practices. National and trial data on PSA growth, screening and biopsy patterns, incidence of prostate cancer, treatment distributions, treatment efficacy, mortality, health-related quality of life, and direct medical expenditure were analyzed. Data were collected from March 18, 2009, to August 15, 2014, and analyzed from November 20, 2012, to December 11, 2015.

INTERVENTIONS

Eighteen screening strategies that vary by start and stop age, screening interval, and criteria for biopsy referral and contemporary or selective treatment practices.

MAIN OUTCOMES AND MEASURES

Life-years (LYs), quality-adjusted life-years (QALYs), direct medical expenditure, and cost per LY and QALY gained.

RESULTS

All 18 screening strategies were associated with increased LYs (range, 0.03-0.06) and costs ($263-$1371) compared with no screening, with the cost ranging from $7335 to $21 649 per LY. With contemporary treatment, only strategies with biopsy referral for PSA levels higher than 10.0 ng/mL or age-dependent thresholds were associated with increased QALYs (0.002-0.004), and only quadrennial screening of patients aged 55 to 69 years was potentially cost-effective in terms of cost per QALY (incremental cost-effectiveness ratio, $92 446). With selective treatment, all strategies were associated with increased QALYs (0.002-0.004), and several strategies were potentially cost-effective in terms of cost per QALY (incremental cost-effectiveness ratio, $70 831-$136 332).

CONCLUSIONS AND RELEVANCE

For PSA screening to be cost-effective, it needs to be used conservatively and ideally in combination with a conservative management approach for low-risk disease.

Discussing and prescribing expensive unfunded anticancer drugs in Australia

OBJECTIVE

Australia has a publicly funded universal healthcare system which heavily subsidises the cost of most registered anticancer drugs. The use of anticancer drugs that are unfunded, that is, not subsidised by the government, entails substantial out-of-pocket costs for patients. We sought to determine how frequently Australian medical oncologists discuss and prescribe unfunded anticancer drugs, and their attitudes and beliefs about their use.

METHODS

Members of the Medical Oncology Group of Australia (MOGA) completed an online survey about their clinical practices over a recent 3-month period. A negative binomial regression model was used to examine the influence of respondent characteristics on the rate of discussions about, and prescription of, unfunded anticancer drugs.

RESULTS

Of the 154 respondents (27% of 575 MOGA members), 92% had discussed and 68% had prescribed at least one unfunded anticancer drug in the last 3 months. Respondents reported discussing unfunded anticancer drugs with an average of 2.5 patients per month (95% CI 2.1 to 2.9), and prescribed them to an average of 0.9 patients per month (95% CI 0.7 to 1.2). The rate of discussing unfunded anticancer drugs was associated with being fully qualified (p=0.01), and being in a metropolitan practice (p=0.009), the rate of prescription was associated only with being in metropolitan practice (p=0.006). The concerns about discussing and prescribing unfunded anticancer drugs rated most important were as follows: 'potential to cause financial hardship' and 'difficulty for patients to evaluate the benefits versus the costs'.

CONCLUSIONS

Australian medical oncologists frequently discuss and prescribe unfunded anticancer drugs, and are concerned about their patients having to face difficult decisions and financial hardship. Further research is needed to better understand the factors that affect how oncologists and patients value expensive, unfunded anticancer drugs.

The evolution of the cancer formulary review in Canada: Can centralization improve the use of economic evaluation?

Public reimbursement of drugs is a costly proposition for health care systems. Decisions to add drugs to the public formulary are often guided by review processes and committees. The evolution of the formulary review process in Canada's publicly funded health system is characterized by increased centralization and systematization. In the past, the review of evidence and recommendation was conducted at the regional level, but was replaced with the pan-Canadian Oncology Drug Review in 2011. We assess the extent to which centralization and systematization of the review process have responded to past challenges, focusing on the use of economic evaluation in the process. Past challenges with economic evaluation experienced by regionalized review committees were identified from literature and qualitative data collected in the province of Nova Scotia. We categorize these using a typology with a macro-, meso, and micro-level hierarchy, which provides a useful framework for understanding at which level change is required, and who has the authority to influence change. Using grounded theory methods, we identify approaches used by Nova Scotia past committee members to compensate for perceived shortcomings of the process. These include an undue reliance on other committee members, on the multidisciplinarity of the committee, and on past decisions. Using a policy analysis approach, we argue that centralization and systematization of the review process only partially address the shortcomings of the previous regionalized process. Lessons from Canada can inform policy discussions across all health systems, where similar challenges with the formulary review process have been identified. © 2016 The Authors. The International Journal of Health Planning and Management published by John Wiley & Sons Ltd.

Clinical Pathways and the Patient Perspective in the Pursuit of Value-Based Oncology Care

The art of practicing oncology has evolved substantially in the past 5 years. As more and more diagnostic tests, biomarker-directed therapies, and immunotherapies make their way to the oncology marketplace, oncologists will find it increasingly difficult to keep up with the many therapeutic options. Additionally, the cost of cancer care seems to be increasing. Clinical pathways are a systematic way to organize and display detailed, evidence-based treatment options and assist the practitioner with best practice. When selecting which treatment regimens to include on a clinical pathway, considerations must include the efficacy and safety, as well as costs, of the therapy. Pathway treatment regimens must be continually assessed and modified to ensure that the most up-to-date, high-quality options are incorporated. Value-based models, such as the ASCO Value Framework, can assist providers in presenting economic evaluations of clinical pathway treatment options to patients, thus allowing the patient to decide the overall value of each treatment regimen. Although oncologists and pathway developers can decide which treatment regimens to include on a clinical pathway based on the efficacy of the treatment, assessment of the value of that treatment regimen ultimately lies with the patient. Patient definitions of value will be an important component to enhancing current value-based oncology care models and incorporating new, high-quality, value-based therapeutics into oncology clinical pathways.

A review of cost communication in oncology: Patient attitude, provider acceptance, and outcome assessment

The American Society of Clinical Oncology released its first guidance statement on the cost of cancer care in August 2009, affirming that patient-physician cost communication is a critical component of high-quality care. This forward-thinking recommendation has grown increasingly important in oncology practice today as the high costs of cancer care impose tremendous financial burden to patients, their families, and the health care system. For the current review, a literature search was conducted using the PubMed and Web of Science databases to identify articles that covered 3 topics related to patient-physician cost communication: patient attitude, physician acceptance, and the associated outcomes; and 15 articles from 12 distinct studies were identified. Although most articles that addressed patient attitude suggested that cost communication is desired by >50% of patients in the respective study cohorts, only <33% of patients in those studies had actually discussed costs with their physicians. The literature on physician acceptance indicated that, although 75% of physicians considered discussions of out-of-pocket costs with patients their responsibility, <30% felt comfortable with such communication. When asked about whether cost communication actually took place in their practice, percentages reported by physicians varied widely from <10% to >60%. The data suggested that cost communication was associated with improved patient satisfaction, lower out-of-pocket expenses, and a higher likelihood of medication nonadherence; none of the studies established causality. Both patients and physicians expressed a strong need for accurate, accessible, and transparent information about the cost of cancer care. Cancer 2017;123:928-39. © 2016 American Cancer Society.

The promise of virtual navigation in cancer care: Insights from patients and health care providers

Virtual navigation (VN) in health care is a proactive process by which patients obtain information and support via Internet resources to manage their illness demands. The objective of this analysis was to explore converging and diverging perspectives of key stakeholders: patients with cancer and Health Care Providers (HCPs), about a cancer-related VN tool called the Oncology Interactive Navigator (OIN™). A qualitative secondary analysis was performed combining data sets from two prior studies exploring perspectives of VN among patients (study 1, n=20) and HCPs (study 2, n=13). An inductive approach was used to explore converging and diverging views across groups. Findings explore how patients' and HCPs' views converge and diverge and the processes necessary to ensure optimal uptake of VN innovations in cancer care.

Physician Experience and Attitudes Toward Addressing the Cost of Cancer Care

PURPOSE

We surveyed US cancer doctors to examine current attitudes toward cost discussions and how they influence decision making and practice management.

METHODS

We conducted a self-administered, anonymous, electronic survey of randomly selected physician ASCO members to evaluate the frequency and nature of cost discussions reported by physicians, attitudes toward discussions of cost in clinics, and potential barriers.

RESULTS

A total of 333 of 2,290 physicians responded (response rate [RR], 15%; adjusted RR after omitting nonpracticing physician ASCO members, 25%), Respondent practice settings were 45% academic and 55% community/private practice. Overall, 60% reported addressing costs frequently/always in clinic, whereas 40% addressed costs rarely/never. The largest reported barrier was lack of resources to guide discussions. Those who reported frequent discussions were significantly more likely to prioritize treatments in terms of cost and believed doctors should explain patient and societal costs. A total of 36%did not believe that doctors should discuss costs with patients. Academic practitioners were significantly less likely to discuss costs (odds ratio [OR], 0.41; P = .001) and felt less prepared for such discussions (OR, 0.492; P = .005) but were more likely to consider costs to the patient (OR, 2.68; P = .02) and society (OR, 1.822; P = .02).

CONCLUSION

Although the majority of respondents believe it is important to consider out-of-pocket costs to patients, a substantial proportion do not discuss or consider costs of cancer care. Lack of consensus on the importance of such discussions and uncertainty regarding the optimal timing and content appear to be barriers to addressing costs of care with patients.

Do new cancer drugs offer good value for money? The perspectives of oncologists, health care policy makers, patients, and the general population

BACKGROUND

In oncology, establishing the value of new cancer treatments is challenging. A clear definition of the different perspectives regarding the drivers of innovation in oncology is required to enable new cancer treatments to be properly rewarded for the value they create. The aim of this study was to analyze the views of oncologists, health care policy makers, patients, and the general population regarding the value of new cancer treatments.

METHODS

An exploratory and qualitative study was conducted through structured interviews to assess participants' attitudes toward cost and outcomes of cancer drugs. First, the participants were asked to indicate the minimum survival benefit that a new treatment should have to be funded by the Spanish National Health System (NHS). Second, the participants were requested to state the highest cost that the NHS could afford for a medication that increases a patient's quality of life (QoL) by twofold with no changes in survival. The responses were used to calculate incremental cost-effectiveness ratios (ICERs).

RESULTS

The minimum improvement in patient survival means that justified inclusions into the NHS were 5.7, 8.2, 9.1, and 10.4 months, which implied different ICERs for oncologists (€106,000/quality-adjusted life year [QALY]), patients (€73,520/QALY), the general population (€66,074/QALY), and health care policy makers (€57,471/QALY), respectively. The costs stated in the QoL-enhancing scenario were €33,167, €30,200, €26,000, and €17,040, which resulted in ICERs of €82,917/QALY for patients, €75,500/QALY for the general population, €65,000/QALY for oncologists, and €42,600/QALY for health care policy makers, respectively.

CONCLUSION

All estimated ICER values were higher than the thresholds previously described in the literature. Oncologists most valued gains in survival, whereas patients assigned a higher monetary value to treatments that enhanced QoL. Health care policy makers were less likely to pay more for therapeutic improvements compared to the remaining participants.

Impact of country-specific EQ-5D-3L tariffs on the economic value of systemic therapies used in the treatment of metastatic pancreatic cancer

BACKGROUND

Previous Canadian cost-effectiveness analyses in cancer based on the EQ-5D-3L (EuroQoL, Rotterdam, Netherlands) have commonly used U.K. or U.S. tariffs because the Canadian equivalent only just recently became available. The implications of using non-Canadian tariffs to inform decision-making are unclear. We aimed to reevaluate an earlier cost-effectiveness analysis of therapies for metastatic pancreatic cancer (originally performed using U.S. tariffs) with tariffs from Canada and various other countries to determine the impact of using non-country-specific tariffs.

METHODS

We used tariffs from Canada, the United States, the United Kingdom, Denmark, France, Germany, Japan, the Netherlands, and Spain to derive EQ-5D-3L utilities for the 10 health states in the pancreatic cancer model. Quality-adjusted life years (qalys) and incremental cost-effectiveness ratios (icers) were generated, and probabilistic sensitivity analyses (psas) were performed.

RESULTS

Canadian utilities are generally lower than the corresponding U.S. utilities and higher than those for the United Kingdom. Compared with the Canadian-valued scenarios, U.S. and U.K. estimates were statistically different for 3 and 9 scenarios respectively. Overall, 35% of the non-Canadian utilities (28 of 80) were significantly different, clinically, from the Canadian values. Canadian qalys were 6% lower than those for the United States and 6% higher than those for the United Kingdom. When comparing the qalys of each treatment with those of gemcitabine alone, the average percent change was +6.8% for a U.S. scenario and -7.5% for a U.K. scenario compared with a Canadian scenario. Consequently, Canadian icers were approximately 5.4% greater than those for the United States and 8.6% lower than those for the United Kingdom. Based on the psas and compared with the Canadian threshold value, the minimum willingness-to-pay threshold at which the combination chemotherapy regimen of gemcitabine-capecitabine is the most cost-effective is $5,239 less than in the United States and $11,986 more than in the United Kingdom.

CONCLUSIONS

The use of non-country-specific tariffs leads to significant differences in the derived utilities, icers, and psa results. Past Canadian EQ-5D-3L-based cost-effectiveness analyses and related funding decisions might need to be re-visited using Canadian tariffs.

Attitude of Iranian Medical Oncologists Toward Economic Aspects, and Policy-making in Relation to New Cancer Drugs

BACKGROUND

Although medical oncologists can have an important role in controlling the cost of cancer treatment, there is little information about their attitudes toward the cost of cancer treatment and the impact of cost on their treatment recommendations, especially in low- and middle-income countries (LMICs). In this study, we assessed the attitude of Iranian medical oncologists toward some economic aspects of new cancer drugs.

METHODS

We translated a questionnaire that was used in similar studies in the United States and Canada into Persian and modified it according to the local setting in Iran. The face and content validity of the questionnaire were assessed by oncologists before being used in the survey. We distributed the questionnaire and collected the data from 80 oncologists who participated in the 13th Annual Congress of the Iranian Society of Medical Oncology and Hematology (ISMOH).

RESULTS

Fifty-two oncologists participated in our study (a response rate of 65%). The majority of oncologists stated that drug costs and patient out-of-pocket (OOP) costs influence their treatment recommendations (92% and 94%, respectively). Most oncologists (70%) felt that they are ready enough to use cost-effectiveness information in their treatment decisions, and 74% believed that patients should only have access to cancer treatments that are cost-effective. Most oncologists agree that the government should have control over drug prices, and more use of cost-effectiveness data is required for decision-making about cancer drug coverage. Ninety-one percent of oncologists said that they always or frequently discuss cancer treatment costs with their patients. Oncologists believed that academic groups (research centers and scientific societies) (81%) and the Ministry of Health (MoH) (43%) are the most eligible groups for determining whether a drug provides good value.

CONCLUSION

Iranian medical oncologists are ready to participate in the health technology assessment and priority-setting process. This situation creates a unique opportunity for the government to rely on scientific societies and find an appropriate solution for the improvement of patients' access to high-quality care.

The implications of out-of-pocket cost of cancer treatment in the USA: a critical appraisal of the literature

Advances in cancer diagnosis and treatment have led to increased societal costs and out-of-pocket patient cost. We reviewed the literature on the impact of out-of-pocket cancer care costs on the patient experience, and described efforts made to address these costs. A critical appraisal of articles published in the USA from 2004 to 2014 was performed. The literature revealed that even insured patients receiving anticancer therapy are vulnerable to financial distress, which can impel patients to borrow money, deplete their savings, or engage in cost-coping strategies including nonadherence to prescribed treatment. Additional research is required to define financial distress risk factors, patient-physician communication of the costs of cancer care, and supportive care models for patients and survivors with substantial financial burdens.

Systemic therapy in stage IV pancreatic cancer: a population-based analysis using the National Cancer Data Base

BACKGROUND

Pancreatic cancer accounts for approximately 7% of all cancer deaths. More than half of all pancreatic cancers are stage IV at diagnosis, where systemic chemotherapy is used with the goal of life prolongation as well as palliation. The patient characteristics and health system factors that drive the use of systemic therapy are unknown.

METHOD

This is a retrospective study of stage IV pancreatic cancer patients (n = 140,210) diagnosed between 2000 and 2011 in the NCDB. NCDB contains approximately 70% of new cancer diagnosis from more than 1500 accredited cancer programs in the United States and Puerto Rico. Chi-squared test was used to determine any differences in characteristics of patients who did or did not receive systemic therapy.

RESULTS

Our study demonstrated that only 49.1% of stage IV pancreatic cancer patients received systemic therapy. The use of systemic therapy is significantly lower in female, African American/Hispanic, patients older than 40 years, those without insurance or with Medicare and Medicaid, higher Charlson Comorbidity Score, poor economic and educational status and in nonacademic centers.

CONCLUSIONS

This is the largest study to evaluate the determinants of systemic therapy use in stage IV pancreatic cancer. The use of systemic therapy was significantly lower in patients older than 40 years, lower educational status, nonprivate insurance and with higher Charlson Comorbidity Scores. In addition, the use of systemic therapy was lower with female sex, African Americans/Hispanic, and lower socio-economic status. Understanding the barriers in the use of systemic therapy as well as appropriate utilization of systemic therapy can both optimize cancer care.

An Anticancer Drug Unit for the whole provincial oncologic network of Piacenza: improving safety and savings

In recent years, the expenditure for cancer care is increased largely due to the increase in cancer prevalence, demographic changes and incorporation into clinical practice of new and expensive drugs. For these reasons, solutions to contain costs are necessaries. The drugs-related expenditure is proportionally higher in oncology than in other medical specialties and overcomes staffing costs for outpatient care. The introduction of additional measures to contain and reduce expenditures such as waste reduction and human resources optimization is highly desirable. On April 2013, we started a day-to-day monitoring of the consumption of drugs and developed an internal protocol for waste minimization, consisting of five measures. A computerized research through Medline, Cancerlit and Embase was performed, applying the words drug waste, cost-containment, Anticancer Drug Unit and stability instructions. Articles and abstracts were also identified by back-referencing from other relevant papers. Selected for the present review were papers published in English without limit of year. The day-to-day monitoring of the consumption of drugs and the internal protocol for waste minimization were able to achieve a saving of <euro>15,700 every month. The projection of an annual cost-saving result of <euro>188.00 corresponds to a recovery of 4 % on the spending for oncologic drugs. Our data show that in a proper structure working according to the standards of quality, safety and sterility, preserving and reusing the drug waste within the limits imposed by the datasheets, it is possible to achieve a cost-containment policy and produce durable benefits.

Controlling health costs: physician responses to patient expectations for medical care

BACKGROUND

Physicians have dual responsibilities to make medical decisions that serve their patients' best interests but also utilize health care resources wisely. Their ability to practice cost-consciously is particularly challenged when faced with patient expectations or requests for medical services that may be unnecessary.

OBJECTIVE

To understand how physicians consider health care resources and the strategies they use to exercise cost-consciousness in response to patient expectations and requests for medical care.

DESIGN

Exploratory, qualitative focus groups of practicing physicians were conducted. Participants were encouraged to discuss their perceptions of resource constraints, and experiences with redundant, unnecessary and marginally beneficial services, and were asked about patient requests or expectations for particular services.

PARTICIPANTS

Sixty-two physicians representing a variety of specialties and practice types participated in nine focus groups in Michigan, Ohio, and Minnesota in 2012 MEASUREMENTS: Iterative thematic content analysis of focus group transcripts

PRINCIPAL FINDINGS

Physicians reported making trade-offs between a variety of financial and nonfinancial resources, considering not only the relative cost of medical decisions and alternative services, but the time and convenience of patients, their own time constraints, as well as the logistics of maintaining a successful practice. They described strategies and techniques to educate patients, build trust, or substitute less costly alternatives when appropriate, often adapting their management to the individual patient and clinical environment.

CONCLUSIONS

Physicians often make nuanced trade-offs in clinical practice aimed at efficient resource use within a complex flow of clinical work and patient expectations. Understanding the challenges faced by physicians and the strategies they use to exercise cost-consciousness provides insight into policy measures that will address physician's roles in health care resource use.

Identifying stakeholder opinion regarding access to “high-cost medicines”: A systematic review of the literature

Objective: To identify the viewpoints and perceptions of different stakeholders regarding high cost medicines (HCMs). Methods: A systematic review of the literature was performed to identify original research articles. Using predefined categories, data related to the viewpoints of different stakeholders was systematically extracted and analyzed. Results: Thirty seven original research articles matched the criteria. The main stakeholders identified include physicians, patients, public and health funding authorities. The influence of media and other economic and ethical issues were also identified in the literature. A large number of stakeholders were concerned about lack of access to HCMs. Physicians have difficulty balancing the the rational use of expensive drugs while at the same time acting as “patients’ advocate”. Patients would like to know about all treatment options, even if they may not be able to afford them. The process and criteria for reimbursement should be transparent and access has to be equitable across patient groups. Conclusion: Access to HCMs could be improved through transparency and involvement of all stakeholders, especially patients and the public. Moral issues and the “rule of rescue” could influence decision-making process significantly. At system level, objectivity is important to ensure that the system is equitable and transparent.

High cancer drug prices in the United States: reasons and proposed solutions

The increase in cancer drug prices in the last 15 years has many contributing factors and is harming our patients and our health care system. It represents to many cancer experts a crossing of a moral line between reasonable profits and profiteering, in a situation involving a human catastrophe: patients who have developed cancer, and who may die because they cannot afford the treatment. With typical out-of-pocket expenses of 20% to 30%, the financial burden of cancer treatment would be $20,000 to 30,000 a year, nearly half of the average annual household income in the United States. Many patients (estimated 10% to 20%) may decide not to take the treatment or may compromise significantly on the treatment plan. This difficult situation poses three relevant questions: (1) Are cancer drug prices too high? (2) Are they hurting patients and our health care system? and (3) Can we do something about it? The answer to each is affirmative. It is also our obligation as cancer doctors to keep patients from "harm and injustice." If high prices make drugs unaffordable and inaccessible, thus causing harm, then we should voice our concerns and advocate for solutions.

Cost-effectiveness of a 14-gene risk score assay to target adjuvant chemotherapy in early stage non-squamous non-small cell lung cancer

Life Technologies has developed a 14-gene molecular assay that provides information about the risk of death in early stage non-squamous non-small cell lung cancer patients after surgery. The assay can be used to identify patients at highest risk of mortality, informing subsequent treatments. The objective of this study was to evaluate the cost-effectiveness of this novel assay. Patients and Methods. We developed a Markov model to estimate life expectancy, quality-adjusted life years (QALYs), and costs for testing versus standard care. Risk-group classification was based on assay-validation studies, and chemotherapy uptake was based on pre- and post-testing recommendations from a study of 58 physicians. We evaluated three chemotherapy-benefit scenarios: moderately predictive (base case), nonpredictive (i.e., the same benefit for each risk group), and strongly predictive. We calculated the incremental cost-effectiveness ratio (ICER) and performed one-way and probabilistic sensitivity analyses. Results. In the base case, testing and standard-care strategies resulted in 6.81 and 6.66 life years, 3.76 and 3.68 QALYs, and $122,400 and $118,800 in costs, respectively. The ICER was $23,200 per QALY (stage I: $29,200 per QALY; stage II: $12,200 per QALY). The ICER ranged from "dominant" to $92,100 per QALY in the strongly predictive and nonpredictive scenarios. The model was most sensitive to the proportion of high-risk patients receiving chemotherapy and the high-risk hazard ratio. The 14-gene risk score assay strategy was cost-effective in 68% of simulations. Conclusion. Our results suggest that the 14-gene risk score assay may be a cost-effective alternative to standard guideline-based adjuvant chemotherapy decision making in early stage non-small cell lung cancer.

Anti-angiogenic agent ramucirumab: meaningful or marginal?

Ramucirumab (IMC-1121B) targets VEGFR-2. Ramucirumab is being investigated in many malignancies including gastric cancer. The Phase III trial in patients with advanced breast cancer failed to improve the primary end point The REGARD trial, a Phase III study, in patients with advanced gastric cancer in the second line setting, had a marginal improvement in overall survival but did not achieve the expected hazard ratio target (of 0.69) and the median duration of therapy with ramucirumab was meager 8 weeks (only 2 weeks longer than the placebo's). Other notable agents in the second line setting are docetaxel and irinotecan. Preliminary results of the RAINBOW trial suggest that ramucirumab may be providing more than marginal advantage. In this review, we briefly summarize the process of angiogenesis and address the emerging cost-benefit issues that surround all newly developed agents including ramucirumab.

Actionable data analytics in oncology: are we there yet?

To operate under a new value-based paradigm, oncology providers must develop the capability to aggregate, analyze, measure, and report their value proposition--that is, their outcomes and associated costs. How are oncology providers positioned currently to perform these functions in a manner that is actionable? What is the current state of analytic capabilities in oncology? Are oncology providers prepared? This line of inquiry was the basis for the 2013 Cancer Center Business Summit annual industry research survey. This article reports on the key findings and implications of the 2013 research survey with regard to data analytic capabilities in the oncology sector. The essential finding from the study is that only a small number of oncology providers (7%) currently possess the analytic tools and capabilities necessary to satisfy internal and external demands for aggregating and reporting clinical outcome and economic data. However there is an expectation that a majority of oncology providers (60%) will have developed such capabilities within the next 2 years.

Does comparative effectiveness research promote rationing of cancer care?

Comparative effectiveness research aims to inform health-care decisions by patients, clinicians, and policy makers. However, questions related to what information is relevant, and how to view the relative attributes of alternative interventions have political, social, and medical considerations. In particular, questions about whether cost is a relevant factor, and whether cost-effectiveness is a desirable or necessary component of such research, have become increasingly controversial as the area has gained prominence. Debate has emerged about whether comparative effectiveness research promotes rationing of cancer care. At the heart of this debate are questions related to the role and limits of patient autonomy, physician discretion in health-care decision making, and the nature of scientific knowledge as an objective good. In this article, we examine the role of comparative effectiveness research in the USA, UK, Canada, and other health-care systems, and the relation between research and policy. As we show, all health systems struggle to balance access to cancer care and control of costs; comparative effectiveness data can clarify choices, but does not itself determine policy or promote rationing of care.

Drug waste minimization as an effective strategy of cost-containment in oncology

Background

Sustainability of cancer care is a crucial issue for health care systems worldwide, even more during a time of economic recession. Low-cost measures are highly desirable to contain and reduce expenditures without impairing the quality of care. In this paper we aim to demonstrate the efficacy of drug waste minimization in reducing drug-related costs and its importance as a structural measure in health care management.

Methods

We first recorded intravenous cancer drugs prescription and amount of drug waste at the Oncology Department of Udine, Italy. Than we developed and applied a protocol for drug waste minimization based on per-pathology/per-drug scheduling of chemotherapies and pre-planned rounding of dosages.

Results

Before the protocol, drug wastage accounted for 8,3% of the Department annual drug expenditure. Over 70% of these costs were attributable to six drugs (cetuximab, docetaxel, gemcitabine, oxaliplatin, pemetrexed and trastuzumab) that we named ‘hot drugs’. Since the protocol introduction, we observed a 45% reduction in the drug waste expenditure. This benefit was confirmed in the following years and drug waste minimazion was able to limit the impact of new pricely drugs on the Department expenditures.

Conclusions

Facing current budgetary constraints, the application of a drug waste minimization model is effective in drug cost containment and may produce durable benefits.

Patient and oncologist discussions about cancer care costs

PURPOSE

Patient out-of-pocket costs are higher for cancer care than for any other health-care sector. Oncologist-patient discussions of costs are not well understood. We conducted an exploratory interview study to examine the frequency, patterns, attitudes, and preferences of both patients and providers on discussion of treatment costs.

METHODS

We conducted semi-structured telephone interviews with oncology clinicians and people receiving chemotherapy at a large nonprofit health system. Multiple investigators conducted thematic analysis using modified content analysis, grounded theory, and interaction analysis methods.

RESULTS

Patient themes included the relevance of cost to their experience, preference for the doctor to be the starting point of cost discussions, but relative infrequency of discussions with doctors or other care team member. Provider themes were an emphasis on clinical benefit above costs, conviction that cost-related decisions should rest with patients, and lack of access to treatment costs. Interest in discussing costs and barriers accessing cost information were common themes from both patients and providers.

CONCLUSIONS

Doctors and patients want to discuss treatment costs but lack access to them. These data support growing evidence for a provider role in discussions of cost during cancer treatment planning.

Patient and oncologist discussions about cancer care costs

PURPOSE

Patient out-of-pocket costs are higher for cancer care than for any other health-care sector. Oncologist-patient discussions of costs are not well understood. We conducted an exploratory interview study to examine the frequency, patterns, attitudes, and preferences of both patients and providers on discussion of treatment costs.

METHODS

We conducted semi-structured telephone interviews with oncology clinicians and people receiving chemotherapy at a large nonprofit health system. Multiple investigators conducted thematic analysis using modified content analysis, grounded theory, and interaction analysis methods.

RESULTS

Patient themes included the relevance of cost to their experience, preference for the doctor to be the starting point of cost discussions, but relative infrequency of discussions with doctors or other care team member. Provider themes were an emphasis on clinical benefit above costs, conviction that cost-related decisions should rest with patients, and lack of access to treatment costs. Interest in discussing costs and barriers accessing cost information were common themes from both patients and providers.

CONCLUSIONS

Doctors and patients want to discuss treatment costs but lack access to them. These data support growing evidence for a provider role in discussions of cost during cancer treatment planning.

Oncologists' and family physicians' views on value for money of cancer and congestive heart failure care

BACKGROUND

Previous studies suggest that cancer-related interventions are valued by policy makers more favorably than interventions for other medical conditions, but the views of practicing physicians have not yet been assessed in Israel. Attitudes and judgments of practicing physicians may assist decision-makers in their deliberations on coverage of new technologies. We conducted a national survey in Israel among oncologists and family physicians to explore their views on access to care, coverage decisions and treatment recommendations for cancer and congestive heart failure (CHF) patients.

METHODS

We administered a web-based survey to 300 family physicians and 156 oncologists. The questionnaire included 24 statements and physicians were asked to indicate their level of agreement with each statement on a 5-point Likert scale, ranging from "strongly agree" to "strongly disagree". Where relevant, physicians were asked to express their views on interventions for cancer and CHF respectively.

RESULTS

Response rates were 39% for family physicians and 36% for oncologists. Participants expressed similar views on cancer and CHF care and no significant differences were found between the two medical specialties. More than 85% of physicians believe that inclusion of a treatment in the National List of Health Services (NLHS) strongly affects their patients' access to care. Approximately 80% suggest that more use of comparative-effectiveness and cost-effectiveness analysis is needed in coverage decisions. The vast majority of respondents (75%) suggest that assessment of value-for-money should be made by an independent (academic) institution or the national committee responsible for recommending coverage decisions, Seventy percent believe that treatments not included in the NLHS should be included in supplementary health insurance programs and only a small minority of respondents (<30%) believe that cancer-related interventions should receive higher priority than non-cancer interventions in coverage decisions.

CONCLUSIONS

Our findings suggest that both oncologists and family physicians value cancer and CHF interventions equally. We could not find evidence for a "cancer premium" as implied from previous surveys and analysis of coverage decisions in various countries.

Which is more valuable, longer survival or better quality of life? Israeli oncologists' and family physicians' attitudes toward the relative value of new cancer and congestive heart failure interventions

OBJECTIVES

We determined how Israeli oncologists and family physicians value life-prolongation versus quality-of-life (QOL)-enhancing outcomes attributable to cancer and congestive heart failure interventions.

METHODS

We presented physicians with two scenarios involving a hypothetical patient with metastatic cancer expected to survive 12 months with current treatment. In a life-prolongation scenario, we suggested that a new treatment increases survival at an incremental cost of $50,000 over the standard of care. Participants were asked what minimum improvement in median survival the new therapy would need to provide for them to recommend it over the standard of care. In the QOL-enhancing scenario, we asked the maximum willingness to pay for an intervention that leads to the same survival as the standard treatment, but increases patient's QOL from 50 to 75 (on a 0-100 scale). We replicated these scenarios by substituting a patient with congestive heart failure instead of metastatic cancer. We derived the incremental cost-effectiveness ratio per quality-adjusted life-year (QALY) gained threshold implied by each response.

RESULTS

In the life-prolongation scenario, the cost-effectiveness thresholds implied by oncologists were $150,000/QALY and $100,000/QALY for cancer and CHF, respectively. Cost-effectiveness thresholds implied by family physicians were $50,000/QALY regardless of the disease type. Willingness to pay for the QOL-enhancing scenarios was $60,000/QALY and did not differ by physicians' specialty or disease.

CONCLUSIONS

Our findings suggest that family physicians value life-prolonging and QOL-enhancing interventions roughly equally, while oncologists value interventions that extend survival more highly than those that improve only QOL. These findings may have important implications for coverage and reimbursement decisions of new technologies.

Cost-effectiveness of systemic therapies for metastatic pancreatic cancer

PURPOSE

Gemcitabine and capecitabine (gem-cap), gemcitabine and erlotinib (gem-e), and folfirinox (5-fluorouracil-leucovorin-irinotecan-oxaliplatin) are new treatment options for metastatic pancreatic cancer, but they are also more expensive and potentially more toxic than gemcitabine alone (gem). We conducted a cost-effectiveness analysis of these treatment options compared with gem.

METHODS

A Markov model was constructed to examine costs and outcomes of gem-cap, gem-e, folfirinox, and gem in patients with metastatic pancreatic cancer from the perspective of a government health care plan. Ontario health economic and costing data (2010 Canadian dollars) were used. Efficacy data for the treatments were obtained from the published literature. Resource utilization data were derived from a chart review of consecutive metastatic patients treated for pancreatic cancer at Princess Margaret Hospital, Toronto, Ontario, 2008-2009, and supplemented with data from the literature. Utilities were obtained by surveying medical oncologists across Canada using the EQ-5D. Incremental cost-effectiveness ratios (icers) were calculated.

RESULTS

The icers for gem-cap, gem-e, and folfirinox compared with gem were, respectively, CA$84,299, CA$153,631, and CA$133,184 per quality-adjusted life year (qaly). The model was driven mostly by drug acquisition costs. Given a willingness-to-pay (wtp) threshold greater than CA$130,000/qaly, folfirinox was most cost-effective treatment. When the wtp threshold was less than CA$80,000/qaly, gem alone was most cost-effective. The gem-e option was dominated by the other treatments.

CONCLUSIONS

The most cost-effective treatment for metastatic pancreatic cancer depends on the societal wtp threshold. If the societal wtp threshold were to be relatively high or if drug costs were to be substantially reduced, folfirinox might be cost-effective.