Category Archives: General Cynicism

The 2011 ASCO meeting ended last week. An estimated 20,000 physicians and others with research and clinical interests in cancer care attended. 4500 abstracts of scientific work were presented with tremendous publicity given to many of the studies, particularly those sponsored by pharmaceutical companies. Reporting on the “event” was obvious on financial pages, daily newspapers and the web.

Drugs and studies touted included the use of exemestane in breast cancer presentation, the use of vemurafenib in melanoma, use of pemetrexed maintenance, bevacizumab in ovarian cancer, targeted therapy, and so on. What was pointedly missing was any emphasis on costs or even mention of the relative cost effectiveness of the various regimens so vigorously publicized.

ASCO accepts a great deal of money from the pharmaceutical industry but even so, as a professional organization in a time when health care spending is soaring, one would think they would pay more than lip service to the problem.

ASCO’s lip service:

In the U.S. health care system, the challenge of coping with cancer, and the effect of both disease and treatment, can be compounded by the uncertainty of whether patients will have access to appropriate care and who will pay for it. It is clear that the costs of cancer care are going up, driven in large part by innovation and by our ability to do more for patients.

In many settings these costs are being shifted to our patients, with a poorly understood effect on access to care and treatment decisions. There is a clear need to better understand the financial effect of cancer care on our patients and how we as oncologists can best promote informed decision making and access to appropriate care.

And:

For decades, it has been clear that a lack of health insurance leads to patients with cancer presenting with more advanced stages of disease at the time of diagnosis and to worse outcomes. The recent passage of the 2010 Patient Protection and Affordable Care Act promises to reduce the ranks of the uninsured, currently estimated at more than 50 million people.

More than 25 million additional Americans may be considered “underinsured” based on inadequate coverage for medical expenses. Ideology aside, we likely can agree that all patients with cancer should have access to quality health care, and that guaranteed access to screening, timely diagnosis, treatment, and supportive care should be our priority for any emerging policy. At this time, there is a patchwork of services and support that can provide financial assistance for patients with cancer.

And:

Despite the availability of financial assistance programs, one-third of patients with cancer report trouble paying their bills and up to 25% report exhausting their savings. These figures are perhaps not surprising in light of the costs of treatment, particularly with novel molecularly targeted agents. Drugs that extend median survival by several months may be priced at as much as $100,000 per patient.

Costs are indeed a problem in our chaotic non-system of care. Where else in the industrialized world do you find 50 million uninsured and people bankrupted by health care costs. Only in America.

When searching the 4500 abstracts of presentations at ASCO 2011 for the word “cost” 286 (6.3% ) studies were found. On review most of these abstracts mention the word “cost” but do no analysis of the actual cost of the intervention.

When the 4500 abstracts were searched for the words “cost effectiveness” a mere 50 (1.1%) studies are highlighted. Once again the great majority of these don’t measure cost effectiveness. In the end fewer than 15 or less than .3% of all presentations were cost effectiveness analyses.

Part of the problem of course is funding. Drug companies are not interested in cost containment, cost efficiency, or value. Rather, their primary goal is ever increasing revenue and profits. They rarely fund cost effectiveness or comparative effectiveness studies unless they are trying to gain an edge over a competitor’s product. And if the study doesn’t show the company’s product positively, they are not publicized, presented or published.

Over the next couple of weeks I’ll review some of the studies of cost effectiveness and point out a few that PHarma did not tout during its publicity blitz last week.

If you are interested you can browse the 2011 abstracts yourself.

Interesting editorial in the Des Moines Registeron traveling for care:

It simply isn’t true. The United States does not lead the pack on health care.

Not according to the World Health Organization, which ranks health care systems of countries all over the world.

Not according to the millions of uninsured Americans who likely think Canadians waiting for elective knee or hip replacements have it pretty good. Most Americans who are uninsured cannot be examined by a family practice doctor or receive mental health treatment or surgery or medications because they cannot afford to pay for them. That is the definition of rationing medical services in a country that spends more on health care than any country on the planet. (Medicynical emphasis)

and:

The most obvious example are the thousands who fill prescriptions at pharmacies in other countries. They may drive across the border or use an Internet pharmacy.

and:

According to one study, 750,000 Americans traveled abroad for health care in 2007 — almost double the number of nonresidents who came to the United States for treatment. Americans, particularly younger ones, head oversees for such services as stem-cell treatments, cosmetic surgery, or tubal ligations. They go elsewhere because it is cheaper.

Medicynical Note: America’s self-delusion does show signs of ending.

This apparently is the new American way. The proposed cuts are based on bogus analysis:

In deriving the 40 percent figure, the Committee apparently misunderstood a finding in a federal Agriculture Department (USDA) report that for every $1 in federal WIC funds spent for WIC foods in 2006, another

• 41 cents in federal funds went for administrative costs plus WIC nutrition services. But: 41 cents out of $1.41 in expenditures equals 29 percent, not 41 percent; and
• over two-thirds of that 29 percent goes not for administrative costs but instead for core WIC services such as breastfeeding support, nutrition education, smoking cessation support, diet and health assessments, substance abuse screening and education, and referrals for immunizations and other needed care.

Medicynical Note: Strange but true. The sad state of the U.S. economy allows such travesties. We’ve sold our soul to the……..banks, corporations and such.

For years our, the U.S. non-healthcare system’s emphasis has been on treatment. We go to extremes at great cost and have little benefit in terms of survival of our population. For example, women, “in large swaths of the U.S. are dying younger than they were a generation ago”.

But over the last decade, the nation has experienced a widening gap between the most and least healthy places to live. In some parts of the United States, men and women are dying younger on average than their counterparts in nations such as Syria, Panama and Vietnam.

Overall the United States is falling further behind other industrialized nations, many of which have also made greater strides in cutting child mortality and reducing preventable deaths.

Medicynical note: We spend more per capita by a wide margin on health care but we forgot that preventing disease offers more benefits (at lower price) than treatment. Meanwhile we reap the consequences of smoking and obesity in our population.

This week’s at ASCO there were numberous examples of studies involving high priced drugs for treating cancer costing in the range of $60,000-$100,000 and more for the drug alone, most with very limited benefit. When one adds up other care required the yearly costs of following these patients approaches $150,000 or more. Consider that one year’s dialysis, all costs included, is in the range of $75,000. Where is the value in these new oncologic advances? True it’s wonderful that there is progress, but at what cost? Affordability? Reality?

Average individuals (median income in U.S. approximately $50,000) will can not pay more than their annual salaries for such limited benefits. Health insurance is a buffer but it doesn’t work if insurers won’t control costs. However, insurers have problems denying patients. The proposals to objectively (non-drug company sponsored evaluations) evaluate cost effectiveness would help with this. If a drug proved no better than standard and/or less expensive options there would be grounds for both the insurance company and physicians to use the more economic alternative. Patients, if they wished, could always opt to pay themselves for the more expensive choice.

Ryan, and his republican colleagues, find regulation to be abhorrent and one can predict that their “plan” will have few protections for those with serious illness and simply allow insurers to discriminate in their provision of coverage (charge unaffordable rates or not offer policies) rather than discriminate against expensive ineffective treatment alternatives.

Our population appears to have reservations about mandating that we all have insurance, high and low risk people. The mindset appears to be that ” I’m not sick, why buy insurance” and that “you can’t make me do anything.” But these same people have no aversion to appearing at ER’s and demanding free care (the most expensive, least efficient available); manipulating the system to get their parents into medicaid covered nursing homes; and demanding affordable health insurance at the moment they become ill.