Rationing has become a contentious, sensitive topic that raised alarm bells — and hackles — during the health-reform debate back in 2010, but a new study finds several areas of agreement among cancer patients, doctors and the public.
Study author Keerthi Gogineni and her team at the University of Pennsylvania wanted to understand what respondents considered the causes of soaring health-industry spending.
Not surprisingly, some of the perennial suspects — pharmaceutical companies and insurance-industry profits — were widely blamed for high health-care spending. But all three groups also laid some responsibility at the feet of hospitals and doctors.
Sixty-nine percent of patients, 81 percent of the general public and 70 percent of doctors said hospitals and doctor conduct unnecessary tests and provide unnecessary treatments.
The researchers also asked what solutions people support to drive down health costs. They posed a series of “what-if” questions about treatments that Gogineni calls “low value and high cost.”
Across the three groups, there was consensus that it’s acceptable if the government’s Medicare program refuses to pay for treatments that do not prolong life or improve the quality of life.
Gogineni, a breast oncologist at Penn’s Abramson Cancer Center, said targeted therapies and genetic profiling make this an exciting time in medicine.
“But, we are also in an era where our health-care costs last year were equivalent of the GDP [gross domestic product] of France, so every time a new technology or drug is available, I think we need to be careful and ask is there a less-expensive, equally effective alternative,” she said.
When not to pay
For the survey, the authors offered up hypotheticals stripped of brand names and specifics, but Gogineni says those scenarios were extracted from real life.
Take the cancer drug bevacizumab, which is sold under the brand name Avastin. In 2011, the U.S. Food and Drug Administration pulled its approval of the medicine for the treatment of advanced breast cancer.
“This is a drug that Medicare still pays for and it costs about $80,000 per patient per year,” Gogineni said. “So this would be an example of a drug that it would be reasonable for Medicare to not pay for. There are alternative drugs for breast cancer that do work.”
Gogineni said her study shows support for the kind of decision-making that often gets labeled as “rationing” but she acknowledges there are lots of “repercussions in public discourse” for politicians that attempt to make changes in Medicare coverage policy.
While the study found strong agreement about restricting government payments for “low value and high cost” care, there were bigger differences of opinion when the researchers asked about treatments that provided convenience, reduced pain or simply improved quality of life as opposed to survival.
“The general public and patients, in general, thought it was not OK for Medicare to refuse to pay for these things,” Gogineni said. “Physicians actually thought it was OK.”
To explain, Gogineni offered another example from her work life caring for patients with breast cancer.
One form of the treatment paclitaxel takes 15 minutes, the other, three hours.
“The difference between the one that’s generic, and the one that’s considered more convenient is $3,000 per dose versus $15,000 per dose,” Gogineni said.
“That’s an example where physicians thought it would be acceptable to sort of restrict access to the treatment that was more expensive but more convenient, whereas, for patients and the general public, they place a higher premium on the ability to be in and out more quickly and have less of an impact on their schedule and the rest of their life,” she said.
Looking at the study
Peter Clark is a bioethicist at Saint Joseph’s University, and a Jesuit priest. He reviewed the results of the Penn survey.
Clark said conversations about health-care rationing sometimes “go better” when they’re called “stewardship of resources.”
“We need to look at this from a common-good perspective,” Clark said. “We are equals. What we need to be able to understand — and educate the public on — is that our medical resources are limited. How do we equitably distribute these so that all people can benefit from these goods?”
Clark works in Philadelphia’s Mercy Health System, which he says cares for the “poorest of the poor.”
“The sisters aren’t turning anyone away,” Clark said. “I think right now we’ve got six people who we are paying for who are undocumented — full freight for dialysis.
“I say to the nuns we have to draw the line somewhere. You get 10 or 15 of these people, that could put the hospital in financial jeopardy, then we are hurting everyone.”
The Penn study has not been published in a peer-reviewed journal.
Gogineni is set to present her findings at the American of Clinical Oncology in Chicago in early June.