“It was the best of times, it was the worst of times…”
This quote from Charles Dickens describing 18th-century London and Paris reflects the incongruity of the environment that we oncologists face in the provision of 21st-century cancer care. The duality of embracing both a new enlightened age of science while concurrently dealing with the potentially crippling budgetary ramifications of those very innovations is not a subtle issue for those of us who spend any time in a cancer center.
I have been a hematologist and medical oncologist for nearly 30 years. Those of us in the field through that period have gotten used to incremental advances in cancer care. With the rare exception of a paradigm-changing medication, we have seen gradual advances over the years, such that the care we provide now is markedly better than that we provided in the early stages of our careers.
We are now, however, in an unprecedented period of new drug development stimulated by the understanding of the normal human genome. By understanding what is “normal,” we can now determine what is anomalous in cancer cells. By doing so, we have a potential window into what makes that cancer cell behave abnormally, and thus provide innumerable targets for new medications to reverse that abnormal behavior.
Simultaneously, we have seen remarkable success in creating drugs that stimulate the human immune system to fight off tumors in circumstances in which the immune system had otherwise been “turned off” by the cancer process. President Jimmy Carter has become the most obvious example of the success of such initiatives.
Pharmaceutical companies have risen to the challenge with rich pipelines of drugs under development, ultimately translating into medications that become available for use in the clinic. The problem, however, is the burgeoning cost of such an endeavor. It has been estimated that U.S. health care costs will reach $4.3 trillion in 2019 and account for 19.3 percent of GDP. Although oncology drug development has accounted for only a fraction of that, it is one of the fastest-growing expenses. Cancer care cost $125 billion in 2010 and is anticipated to be $158 billion in 2020. This growth is unsustainable without the enterprise collapsing under its own weight.
We as oncologists have been asked to function as fiduciaries of the health care dollar. New programs aimed at cost savings, limiting waste and variability and providing patient-centric quality and value are now being integrated into the care models of major payers and businesses. These fee-for-value programs are becoming more prominent in the marketplace and are gradually replacing the historic fee-for-service payment systems previously routine.
However, cost savings can go just so far with practitioners functioning as sentinels at the gate of health care expenditures. The cost of pharmaceuticals is not modulated by an obvious “market.” Payers are obligated to reimburse for the use of medications once the Food and Drug Administration approves them regardless of whether the drugs in question are marginal improvements over pre-existing formulae or groundbreaking. In fact, the FDA does not consider cost at all in its decision making. Medicare cannot negotiate these costs and are at the mercy of the pharmaceutical industry’s calculus in determining price tag of a drug.
Admittedly, health care systems, providers and pharmaceutical companies have been complicit in creating an environment of unrealistic expectations for many of these drugs. Many of these new anti-cancer medications can cost $10,000–$50,000 per month. Research and development, innovation expenses and the price of bringing a drug to market have all been quoted as reasons for the drug costs. As costs have escalated skyward, however, more of that expense has shifted to the consumer, resulting in the new concept of “financial toxicity” implying that the cost of medications itself is yet another potential source of diminished quality of life in our cancer patients above and beyond the misfortune of their disease and side effects of its treatment. There are compelling data demonstrating a rise in personal bankruptcies in cancer patients as well as instances in which patients become noncompliant with treatment regimens because of cost, ultimately impacting outcomes.
Ultimately, time will tell whether this is truly the “best of times” or “worst of times.” Although practitioners can assist as good stewards of the health care dollar, eliminating waste and providing compassionate evidence-based care, it will be difficult to deflect the cost curve without the price of pharmaceuticals more accurately reflecting their value to society. Our current system has decoupled the cost and value propositions for these medications. We cannot seriously tackle the skyrocketing expense of cancer care without acknowledging this.
