stakeholder perspectives on the cost of cancer care neal j. meropol, m.d. fox chase cancer center...
TRANSCRIPT
![Page 1: Stakeholder perspectives on the cost of cancer care Neal J. Meropol, M.D. Fox Chase Cancer Center Philadelphia, PA May 30, 2009 Economics of Cancer Care:](https://reader038.vdocuments.site/reader038/viewer/2022110405/56649ee05503460f94bf050d/html5/thumbnails/1.jpg)
Stakeholder perspectives on the cost of cancer care
Neal J. Meropol, M.D.Fox Chase Cancer Center
Philadelphia, PAMay 30, 2009
Economics of Cancer Care:It’s Everyone’s Problem
![Page 2: Stakeholder perspectives on the cost of cancer care Neal J. Meropol, M.D. Fox Chase Cancer Center Philadelphia, PA May 30, 2009 Economics of Cancer Care:](https://reader038.vdocuments.site/reader038/viewer/2022110405/56649ee05503460f94bf050d/html5/thumbnails/2.jpg)
Why focus on oncology?
• Cancer is life-threatening
• Cancer is common
• Treatments and diagnostics are increasingly costly
• High cost drugs command attention
• Treatments have only modest benefit in many circumstances
![Page 3: Stakeholder perspectives on the cost of cancer care Neal J. Meropol, M.D. Fox Chase Cancer Center Philadelphia, PA May 30, 2009 Economics of Cancer Care:](https://reader038.vdocuments.site/reader038/viewer/2022110405/56649ee05503460f94bf050d/html5/thumbnails/3.jpg)
What the media tells us
• “Targeted therapy save lives!”
• “We’re going to bankrupt the economy!”
• “The pharmaceutical industry is evil!”
![Page 4: Stakeholder perspectives on the cost of cancer care Neal J. Meropol, M.D. Fox Chase Cancer Center Philadelphia, PA May 30, 2009 Economics of Cancer Care:](https://reader038.vdocuments.site/reader038/viewer/2022110405/56649ee05503460f94bf050d/html5/thumbnails/4.jpg)
What we should be asking
• What does this mean for individual patients and their decisions about treatment?
• What does this mean for how we invest in, develop, and pay for new cancer treatments?
![Page 5: Stakeholder perspectives on the cost of cancer care Neal J. Meropol, M.D. Fox Chase Cancer Center Philadelphia, PA May 30, 2009 Economics of Cancer Care:](https://reader038.vdocuments.site/reader038/viewer/2022110405/56649ee05503460f94bf050d/html5/thumbnails/5.jpg)
The Cost of Care Has Wide Impact
PatientsProducers Providers
Payers Employers
![Page 6: Stakeholder perspectives on the cost of cancer care Neal J. Meropol, M.D. Fox Chase Cancer Center Philadelphia, PA May 30, 2009 Economics of Cancer Care:](https://reader038.vdocuments.site/reader038/viewer/2022110405/56649ee05503460f94bf050d/html5/thumbnails/6.jpg)
What are we spending?
![Page 7: Stakeholder perspectives on the cost of cancer care Neal J. Meropol, M.D. Fox Chase Cancer Center Philadelphia, PA May 30, 2009 Economics of Cancer Care:](https://reader038.vdocuments.site/reader038/viewer/2022110405/56649ee05503460f94bf050d/html5/thumbnails/7.jpg)
Adapted from C. Borger, et al. Health Affairs 25(2): w61-w73, 2006; Reproduced in Meropol and Schulman, J Clin Oncol, 2007
US Health Expenditures and GDP
![Page 8: Stakeholder perspectives on the cost of cancer care Neal J. Meropol, M.D. Fox Chase Cancer Center Philadelphia, PA May 30, 2009 Economics of Cancer Care:](https://reader038.vdocuments.site/reader038/viewer/2022110405/56649ee05503460f94bf050d/html5/thumbnails/8.jpg)
Growth in healthcare spending is greater than growth in GDP
Healthcare Costs: A Primer, Kaiser Family Foundation, 2007
![Page 9: Stakeholder perspectives on the cost of cancer care Neal J. Meropol, M.D. Fox Chase Cancer Center Philadelphia, PA May 30, 2009 Economics of Cancer Care:](https://reader038.vdocuments.site/reader038/viewer/2022110405/56649ee05503460f94bf050d/html5/thumbnails/9.jpg)
More spending = Better health
Meropol and Schulman, J Clin Oncol, 2007
![Page 10: Stakeholder perspectives on the cost of cancer care Neal J. Meropol, M.D. Fox Chase Cancer Center Philadelphia, PA May 30, 2009 Economics of Cancer Care:](https://reader038.vdocuments.site/reader038/viewer/2022110405/56649ee05503460f94bf050d/html5/thumbnails/10.jpg)
Cancer Survival Worldwide
adapted from Coleman et al. Lancet Oncology, 2008http://www.oecd.org/document/16/0,3343,en_2649_34631_2085200_1_1_1_1,00.html
0102030405060708090
100
Slova
kia
($1.
3K)
Spain ($
2.5K
)
Japan
($2.
6K)
UK ($2.
8K)
Austra
lia ($
3.1K
)
US ($6.
7K)
BreastColon (men)Prostate
![Page 11: Stakeholder perspectives on the cost of cancer care Neal J. Meropol, M.D. Fox Chase Cancer Center Philadelphia, PA May 30, 2009 Economics of Cancer Care:](https://reader038.vdocuments.site/reader038/viewer/2022110405/56649ee05503460f94bf050d/html5/thumbnails/11.jpg)
NIH Estimates for Cancer Costs in the United States: 2007
• Total costs: $219 billion
• $89 billion for direct medical costs
• US spends ~$2 trillion on healthcare per year
American Cancer Society
![Page 12: Stakeholder perspectives on the cost of cancer care Neal J. Meropol, M.D. Fox Chase Cancer Center Philadelphia, PA May 30, 2009 Economics of Cancer Care:](https://reader038.vdocuments.site/reader038/viewer/2022110405/56649ee05503460f94bf050d/html5/thumbnails/12.jpg)
Oncology Drug Contribution to Spending Growth - 2007
Growth RateAll clinic drug expenditures 9.9%Antineoplastics 16%
*Cancer drugs are #1 among hospital and clinic drug expenditures*In general, drugs account for only 10% of healthcare spending
Hoffman JM et al. Am J Health-Syst Pharm, 2009
![Page 13: Stakeholder perspectives on the cost of cancer care Neal J. Meropol, M.D. Fox Chase Cancer Center Philadelphia, PA May 30, 2009 Economics of Cancer Care:](https://reader038.vdocuments.site/reader038/viewer/2022110405/56649ee05503460f94bf050d/html5/thumbnails/13.jpg)
Wong et al. Cancer, 2009
Cost Effectiveness of Colon Cancer Drug Treatment
A
BC
D
E
F
G
H
I
$0
$20,000
$40,000
$60,000
$80,000
$100,000
$120,000
$140,000
$160,000
$180,000
$200,000
30 40 50 60 70 80 90 100 110 120
Effectiveness (weeks)
Co
st
A B C D E F G H I not dominated
![Page 14: Stakeholder perspectives on the cost of cancer care Neal J. Meropol, M.D. Fox Chase Cancer Center Philadelphia, PA May 30, 2009 Economics of Cancer Care:](https://reader038.vdocuments.site/reader038/viewer/2022110405/56649ee05503460f94bf050d/html5/thumbnails/14.jpg)
Cost Effectiveness of Adjuvant Therapy for Stage III Colon Cancer
British payer perspective• Addition of oxaliplatin to FU/LV (MOSAIC)
– £ 2970 per QALY gained• Capecitabine vs. Mayo Clinic FU/LV
– £ 3320 savings per patient• Extrapolated: FOLFOX vs. Capecitabine
– £ 13,000 per QALY gained
Pandor et al. Health Technology Assessment, 2006
![Page 15: Stakeholder perspectives on the cost of cancer care Neal J. Meropol, M.D. Fox Chase Cancer Center Philadelphia, PA May 30, 2009 Economics of Cancer Care:](https://reader038.vdocuments.site/reader038/viewer/2022110405/56649ee05503460f94bf050d/html5/thumbnails/15.jpg)
Considerations for Innovators(producers)
![Page 16: Stakeholder perspectives on the cost of cancer care Neal J. Meropol, M.D. Fox Chase Cancer Center Philadelphia, PA May 30, 2009 Economics of Cancer Care:](https://reader038.vdocuments.site/reader038/viewer/2022110405/56649ee05503460f94bf050d/html5/thumbnails/16.jpg)
It costs $1 billion to develop a new drug
Adams and Brantner. Health Affairs, 2006
![Page 17: Stakeholder perspectives on the cost of cancer care Neal J. Meropol, M.D. Fox Chase Cancer Center Philadelphia, PA May 30, 2009 Economics of Cancer Care:](https://reader038.vdocuments.site/reader038/viewer/2022110405/56649ee05503460f94bf050d/html5/thumbnails/17.jpg)
A double-edged sword
• Biotechnology/oncology is an attractive realm for investment
• Patients benefit from new drugs• However,
– Potential for profit-driven inefficiencies in drug development
– Incentives for marginally better treatments– Potential disincentive for identification of
predictive markers/personalized medicine
![Page 18: Stakeholder perspectives on the cost of cancer care Neal J. Meropol, M.D. Fox Chase Cancer Center Philadelphia, PA May 30, 2009 Economics of Cancer Care:](https://reader038.vdocuments.site/reader038/viewer/2022110405/56649ee05503460f94bf050d/html5/thumbnails/18.jpg)
Some assumptions about targeted/personalized drug development
may not be true• Certainly true
– Smaller market - bad– Competitive advantage - good
• Uncertain– Drug development will be faster, cheaper, more
successful?– Patients will stay on treatment longer?– New markets will be identified?– Pricing premium based on value and novelty will offset
narrowed market
![Page 19: Stakeholder perspectives on the cost of cancer care Neal J. Meropol, M.D. Fox Chase Cancer Center Philadelphia, PA May 30, 2009 Economics of Cancer Care:](https://reader038.vdocuments.site/reader038/viewer/2022110405/56649ee05503460f94bf050d/html5/thumbnails/19.jpg)
The impact on patients
![Page 20: Stakeholder perspectives on the cost of cancer care Neal J. Meropol, M.D. Fox Chase Cancer Center Philadelphia, PA May 30, 2009 Economics of Cancer Care:](https://reader038.vdocuments.site/reader038/viewer/2022110405/56649ee05503460f94bf050d/html5/thumbnails/20.jpg)
Weinfurt, K. P. J Clin Oncol; 25:223-227 2007
Prospect Theory: People Care More About Loss Than Gain
Therefore, cancer patients may place
high value on treatments with “modest” benefit
![Page 21: Stakeholder perspectives on the cost of cancer care Neal J. Meropol, M.D. Fox Chase Cancer Center Philadelphia, PA May 30, 2009 Economics of Cancer Care:](https://reader038.vdocuments.site/reader038/viewer/2022110405/56649ee05503460f94bf050d/html5/thumbnails/21.jpg)
Individual patients feel the burden
• Insurance premiums• Co-pays• Co-insurance• Tiered formularies• Part D donut hole
Increased financial burden on families
Delay in seeking treatment
Limit/alter treatment
![Page 22: Stakeholder perspectives on the cost of cancer care Neal J. Meropol, M.D. Fox Chase Cancer Center Philadelphia, PA May 30, 2009 Economics of Cancer Care:](https://reader038.vdocuments.site/reader038/viewer/2022110405/56649ee05503460f94bf050d/html5/thumbnails/22.jpg)
The Financial Burden of Cancer
• 29% of families spend >10% of income on cancer (Banthin, JAMA, 2006)
• KFF/USA Today Survey– Burden of costs on the family – 17% major burden– 25% used up all or most of savings– 13% borrowed from relatives– 11% sought charity– 8% delayed or did not get care because of cost– 22% lower income
• 10% spent >%18K out-of-pocket in 2003-04 (Goldman, Health Affairs, 2006)
![Page 23: Stakeholder perspectives on the cost of cancer care Neal J. Meropol, M.D. Fox Chase Cancer Center Philadelphia, PA May 30, 2009 Economics of Cancer Care:](https://reader038.vdocuments.site/reader038/viewer/2022110405/56649ee05503460f94bf050d/html5/thumbnails/23.jpg)
Cost is a component of decision making for patients
Ben
efits
Monetary Costs
Toxicities
![Page 24: Stakeholder perspectives on the cost of cancer care Neal J. Meropol, M.D. Fox Chase Cancer Center Philadelphia, PA May 30, 2009 Economics of Cancer Care:](https://reader038.vdocuments.site/reader038/viewer/2022110405/56649ee05503460f94bf050d/html5/thumbnails/24.jpg)
Patients Feel Ill-Equipped to Consider Costs
• How do I ask about costs, about value?• Will I anger my doctor?• How can I predict costs of treatment?• Where can I get information?• How can I discuss this with my family?• How do I access patient assistance plans?• I don’t have the resources to help me
navigate this
![Page 25: Stakeholder perspectives on the cost of cancer care Neal J. Meropol, M.D. Fox Chase Cancer Center Philadelphia, PA May 30, 2009 Economics of Cancer Care:](https://reader038.vdocuments.site/reader038/viewer/2022110405/56649ee05503460f94bf050d/html5/thumbnails/25.jpg)
What is the oncologist’s role, and how do we deal with this
patient issue?
![Page 26: Stakeholder perspectives on the cost of cancer care Neal J. Meropol, M.D. Fox Chase Cancer Center Philadelphia, PA May 30, 2009 Economics of Cancer Care:](https://reader038.vdocuments.site/reader038/viewer/2022110405/56649ee05503460f94bf050d/html5/thumbnails/26.jpg)
Are oncologists to blame for rising costs?
• Oncologist income is tied to chemotherapy administration
• Aggressive use of drugs, diagnostics, and technologies, sometimes with limited evidence
• Lots of chemotherapy in the weeks before death
• It’s easy to give drugs; it’s hard to talk about stopping
![Page 27: Stakeholder perspectives on the cost of cancer care Neal J. Meropol, M.D. Fox Chase Cancer Center Philadelphia, PA May 30, 2009 Economics of Cancer Care:](https://reader038.vdocuments.site/reader038/viewer/2022110405/56649ee05503460f94bf050d/html5/thumbnails/27.jpg)
On the other hand….
• Who creates demand?– Patients, society?
• Why focus on oncologists?– Radiation, diagnostic radiology, surgery
• Other members of the supply chain certainly seek to maximize profit– Drug and device makers, pharma, insurers
![Page 28: Stakeholder perspectives on the cost of cancer care Neal J. Meropol, M.D. Fox Chase Cancer Center Philadelphia, PA May 30, 2009 Economics of Cancer Care:](https://reader038.vdocuments.site/reader038/viewer/2022110405/56649ee05503460f94bf050d/html5/thumbnails/28.jpg)
Oncologists Feel Ill-Equipped to Consider Costs
• How do I talk about costs, about value?• How can I predict costs of treatment?• Where do I find the time?• How do I balance my dual responsibilities to
society and my individual patients?• I don’t have the resources to help me
navigate this
![Page 29: Stakeholder perspectives on the cost of cancer care Neal J. Meropol, M.D. Fox Chase Cancer Center Philadelphia, PA May 30, 2009 Economics of Cancer Care:](https://reader038.vdocuments.site/reader038/viewer/2022110405/56649ee05503460f94bf050d/html5/thumbnails/29.jpg)
The High Cost of Care Can Widen Disparities in Cancer Outcomes
![Page 30: Stakeholder perspectives on the cost of cancer care Neal J. Meropol, M.D. Fox Chase Cancer Center Philadelphia, PA May 30, 2009 Economics of Cancer Care:](https://reader038.vdocuments.site/reader038/viewer/2022110405/56649ee05503460f94bf050d/html5/thumbnails/30.jpg)
Ward, E. et al. CA Cancer J Clin 2008;58:9-31.
Changes in Health Insurance Premiums, Inflation, and Workers' Earnings, 2000-2007
INSURANCE
INFL
EARNINGS
![Page 31: Stakeholder perspectives on the cost of cancer care Neal J. Meropol, M.D. Fox Chase Cancer Center Philadelphia, PA May 30, 2009 Economics of Cancer Care:](https://reader038.vdocuments.site/reader038/viewer/2022110405/56649ee05503460f94bf050d/html5/thumbnails/31.jpg)
As healthcare costs rise, employers will:
• Reduce benefits
• Reduce wages
• Become non-competitive
![Page 32: Stakeholder perspectives on the cost of cancer care Neal J. Meropol, M.D. Fox Chase Cancer Center Philadelphia, PA May 30, 2009 Economics of Cancer Care:](https://reader038.vdocuments.site/reader038/viewer/2022110405/56649ee05503460f94bf050d/html5/thumbnails/32.jpg)
As healthcare costs rise, providers will provide:
• Less “off-label” treatment
• Less charity care
![Page 33: Stakeholder perspectives on the cost of cancer care Neal J. Meropol, M.D. Fox Chase Cancer Center Philadelphia, PA May 30, 2009 Economics of Cancer Care:](https://reader038.vdocuments.site/reader038/viewer/2022110405/56649ee05503460f94bf050d/html5/thumbnails/33.jpg)
Ward, E. et al. CA Cancer J Clin 2008;58:9-31.
Health Insurance Coverage Among Individuals Under Age 65 Years, 2006
(in Millions)
![Page 34: Stakeholder perspectives on the cost of cancer care Neal J. Meropol, M.D. Fox Chase Cancer Center Philadelphia, PA May 30, 2009 Economics of Cancer Care:](https://reader038.vdocuments.site/reader038/viewer/2022110405/56649ee05503460f94bf050d/html5/thumbnails/34.jpg)
Ward, E. et al. CA Cancer J Clin 2008;58:9-31.
Colorectal Cancer Stage is Higher Stage Among
Private
Uninsured/Medicaid
Wh
ite
AA
His
pan
ic
![Page 35: Stakeholder perspectives on the cost of cancer care Neal J. Meropol, M.D. Fox Chase Cancer Center Philadelphia, PA May 30, 2009 Economics of Cancer Care:](https://reader038.vdocuments.site/reader038/viewer/2022110405/56649ee05503460f94bf050d/html5/thumbnails/35.jpg)
Ward, E. et al. CA Cancer J Clin 2008;58:9-31.
Colorectal Cancer
Survival is Worse Among
Uninsured
Private
Uninsured
Medicaid
Wh
ite
AA
His
pan
ic
![Page 36: Stakeholder perspectives on the cost of cancer care Neal J. Meropol, M.D. Fox Chase Cancer Center Philadelphia, PA May 30, 2009 Economics of Cancer Care:](https://reader038.vdocuments.site/reader038/viewer/2022110405/56649ee05503460f94bf050d/html5/thumbnails/36.jpg)
Can we afford the cancer care of the future?
• % of GDP spent on cancer care is currently small• However
– cancer care is an increasing component of healthcare expenditures
– Cost is an increasing consideration for patients, and can lead to disparities in care
– Personalized medicine may have unintended economic consequences for the cancer enterprise
• Policy solutions must integrate various perspectives, and ultimately address the value of specific interventions and distribution of finite resources