IOM Cancer Report

The Institute of Medicine this week released “Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis.” [full report; briefing slides]

The report lays out the cancer care continuum in this way.

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Two of the reasons the IOM describes cancer care as being “in crisis” is the degree to which they say that the current system is not patient centered and evidence based. When searching for value in cancer care or health care generally, you are really asking whether a given course of treatment improves quality of life, extends life and how much it costs. If you can answer these three questions, then you have a chance of asking (and maybe answering) the question of “is this worth it?” The “is it worth it?” question is relevant at both an individual, but also at a system and payer level (for Medicare in particular, given that 8 in 10 decedents in the U.S. are insured by Medicare and the fact that cancer disproportionately affects older persons, which is a bit of a tautology since it is the second leading cause of death in the U.S.).

The key in trying to join “patient centeredness” with the “evidence base” at the patient level are the items in the purple box (care planning, palliative care, imagining and responding to sequelae of symptoms and burden to patients and caregivers, etc). This is one place those three questions should be asked, discussed and answered over and over, since this is where the choices that patients have in treating cancer (say if covered by Medicare) get banged out into an actual treatment trajectory.

The choices that are offered to patients are also important, and Medicare has the legal/regulatory authority to make coverage decisions and truncate choices, but of course this is politically very difficult.

Our team here at Duke will hopefully be publishing the results of a study we have just completed in which patients with cancer and their caregivers identify what treatment options are most important if a serious resource constraint were imposed in Medicare, as it provides some insight, both into how conversations that are inherent in the purple arrow above can be structured, as well as how policy at the Medicare-level might be altered.

Even more on skin in the game and Cancer

Yousuf Zafar, my colleague here at Duke presented today at the American Society of Clinical Oncology annual meeting on a study showing out of pocket costs for moderate-to-low income Cancer patients averaged $712 per month (I am a co-author). The study shows a variety of mechanisms that patients use to cope with these costs, including not filling prescriptions, cutting pills in half, and going into debt. I cannot share more details on the blog at this time because the paper has not yet been accepted for publication.

However, the role of out of pocket costs and its role in health care and health reform has gotten a great deal of attention of late. Austin and Aaron have been writing a great deal about skin in the game, including more today from Austin where he usefully points out that premiums are a large part of health care expenditures for Medicare beneficiaries. I wrote last week on a recent study showing that 1 in 10 Cancer patients didn’t fill their initial anti-Cancer medication due to out of pocket costs. Yousuf’s new study helps to further demonstrate that sick people (Cancer in these studies) pay quite a lot out of pocket for health care in our current system. Such cost sharing lessens the amount of care received by sick people, and it is unclear if the blunt tool of out of pocket costs does a good job of prioritizing wasteful from productive spending. As I said last week, if you are worried about costs and rationing of care, high deductibles for sick people should have you worried.