“There is a lot of waste in medicine,” said hematologist/oncologist Stuart Goldberg, MD, of the John Theurer Cancer Center at Hackensack University Medical Center in New Jersey and chief scientific officer at Cota, a health care data and analytics company that bridges precision medicine to population health.
By some estimates, up to one-third of health care spending is unnecessary, he noted.
Waste contributes importantly to financial distress for patients, sometimes called “financial toxicity” — a problem that is getting worse as the costs of medications and diagnostics escalate.
“The shift from intravenous medications to pills may improve quality issues for our patients but also affects their pocketbook. The cost for pills is borne much more by the patient than hospital-based infusions,” Dr Goldberg explained. “Patients are paying more out of pocket…if chemo pills cost $10,000 a month retail, then a 10% copay is $12,000 a year. That can quickly drain a patient’s nest-egg.”
Overly aggressive or futile care at the end of a patient’s life is particularly costly, both in dollars and in terms of patients’ quality of life.
“There’s a huge ramp-up in costs as death approaches,” Dr Goldberg said. “In cancer and some other diseases, we can do more, but should we?”
Poor information-sharing among different health care systems is another big problem, in part because it leads to duplicate lab tests.
“Everybody thought computers were going to allow us to follow patient care wherever a patient goes. But from a business perspective, we don’t want a competing hospital to access our records,” Dr Goldberg said. “I get a lot of patients for second or third opinions for whom we have no labs. We can wait weeks to get them, but it’s easier to repeat a test that’s already been done.”
Without proper biomarker and genetic testing in the first place, before treatment plans are devised, expensive treatments are also likely to be misused.
“Prescribing an expensive targeted agent to a patient whose tumor doesn’t harbor the relevant gene mutation makes little clinical sense. And not offering the targeted agent to a patient who has the mutation because you didn’t know deprives the patient of a better chance at success. But many diagnostic biomarker tests are not covered by insurance.
“Genomic tests often cost $3000 to $4000 and may not be covered by private insurers or Medicare,” Dr Goldberg added. “You wind up giving patients therapies that don’t work because you didn’t know there’s a better therapy available to your patient. It hurts the patient and wastes money.”
Communication Is Critical
Communication with patients about the goals, risks, and costs of therapy is crucially important.
A recent analysis of patient conversations for 56 oncologists between 2010 and 2013, published in the Journal of Oncology Practice, found that costs were discussed in only 22% of visits and lasted, on average, for 33 seconds.1 Patients tended to raise concerns about the costs of tests, while oncologists more frequently initiated conversations about the cost of antineoplastic agents.
Patients frequently misunderstand the goals of treatment or tests, Dr Goldberg noted.
“Today I sat with a patient with advanced gastric cancer, 3 months into treatment,” he said. “I told her we’re coming up on a CT [computerized tomography] scan. She said if the CT scan is good: ‘I’m done, right?’ I said, ‘no, you’re going to be on this treatment forever.’ She looked like I was talking in tongues. She didn’t understand that the goal of therapy was to slow the cancer, not cure it. But she was totally unaware.”
Discussing treatment futility is similarly fundamental, but talking to a patient about her impending death can be challenging for all involved.
According to Dr Goldberg, “we have technical skills and new drugs, and we want to offer them to the patient without asking the patient: ‘when is enough, enough?’
“It is a very difficult discussion to have. It’s uncomfortable. It also turns out patients don’t bring it up very often. They’ll tell family members they don’t want any more chemotherapy. But they often don’t tell their doctors or health care team, because they don’t want to tell doctor they’re giving up.”
The American Society of Clinical Oncology (ASCO) released a new guideline to help improve clinician communication with patients.2 It calls on clinicians to clearly convey, and to make sure that each patient really understands the prognosis and treatment options — and to discuss the patient’s values, goals, and priorities to make sure that treatment plans reflect the patient’s needs and wishes.2
When a patient is in the ICU, she may not communicate as easily and is likely to die in the most expensive medical environment, Dr Goldberg said.
Moving these conversations to earlier points in the disease trajectory helps make sure that a patient’s wishes and values are honored and avoids waste, he added.
With colleagues, Dr Goldberg developed a 7-item questionnaire that can be administered at the start of every cycle of chemotherapy.3
“These are very nonthreatening questions: are you having pain? Are you able to get out of bed? Do you have financial difficulties? These are basic questions about issues that can cause distress,” he said.
Collectively, distress on multiple fronts — dealing with pain and depression, and concern about being a burden to loved ones, for example — can indicate that the end of a patient’s life is approaching.
“Being generally distressed correlates very strongly with how many months a patient may have left to live,” Dr Goldberg said. “So what we found was you can ask how distressed patients are, and if you observe a total distress score that is high, then, well, that is when you talk not just about distress but the patient’s goals for therapy, and whether palliative care or hospice might be more appropriate.”
That approach “flips the paradigm,” Dr Goldberg said.
Critics of the Affordable Care Act raised the specter of “death panels,” he said. “The idea was, doctors would look at tables and say ‘this patient will die so we shouldn’t do something.’ But if you let the patient tell you when they feel distressed, since we know that correlates with survival, we can deal with the distress by offering aggressive care or palliative care.”
“That allows us to get the timing right for end-of-life discussions,” he said. “These discussions are important. Even Medicare has started to pay for palliative care consultations. These conversations align treatments with patient wishes, and probably save money.”
Stuart Goldberg, MD, is a hematologist/oncologist at the John Theurer Cancer Center at Hackensack University Medical Center in New Jersey and chief scientific officer at Cota, a health care data and analytics company that bridges precision medicine to population health.
- Hunter WG, Zafar SY, Hesson A, et al. Discussing health care expenses in the oncology clinic: analysis of cost conversations in outpatient encounters. J Oncol Pract. 2017 August 23. doi: 10.1200/JOP.2017.022855 [Epub ahead of print]
- Gilligan T, Coyle N, Frankel RM, et al. Patient-clinician communication: American Society of Clinical Oncology consensus guideline. J Clin Oncol. 2017 Sep 11. doi: 10.1200/JCO.2017.75.2311 [Epub ahead of print]
- Goldberg SL, Paramanathan D, Arunajadai S, et al. Predictive value of the patient reported outcome “living with cancer” instrument on overall survival in advanced cancer patients: a tool for guiding timing of palliative care. J Clin Oncol. 2017;35(suppl; abstr 10025).
This article originally appeared on Cancer Therapy Advisor