Economics of Cancer Care Delivery: Opportunities and Challenges

Economics of Cancer Care, 2019

Hearing the words “you have cancer” is extremely distressing and immediately raises a number of concerns about life expectancy, functional status, income and employment, family relationships, and the impact of treatments on each of these. Multiple surveys have documented the classic response mechanisms of denial, anger, bargaining, and sadness, but immediate practical considerations, such as impact on job, income, bills, and quality of life, dominate early conversations. Increasingly, another serious consideration is coming to the forefront—that of the costs of care, especially the self-borne ones. This tends to arise once the treatment plan is formulated, as the direct line of association crystallizes between the diagnosis and the plan of action. It is also highly dependent on the presence or absence of insurance benefits, the details of those benefits, and how well they are understood by the patient. A continuous and rapid rise over the last few years of these patient-borne costs, which are projected to persist and increase over an indeterminate period of time, not only threatens one’s ability to pay for treatment but also the access to such treatment. As the article by Paul points out, once the words “you have cancer” are spoken, everything that contributes to a delay in getting to a treatment plan, or at least information about the diagnosis, becomes high priority for most individuals. In this article, at least one-third to one-half of patients in Sydney Australia reported treatment-phase dependent concerns about access to treatment, especially those of lower socioeconomic status, those who were younger, and those born outside of Australia. The same concerns are true in the United States, especially in rural areas, for which insurance coverage is a contributing factor. In rural areas, Medicare is the predominant insurance for eligible individuals, and having no insurance has decreased slightly to approximately 15% to 25%. Initiation of the treatment itself, when disease is evaluable, provides a temporary emotional buffer to the costs of treatment, as it at least contributes subjective data about the imputed benefit-to-cost ratio. This is much more nebulous when the treatments are purposed to prevent recurrence, as the benefit/cost ratio is much more statistical in nature, rather than directly evaluable. Once treatment is concluded, as the proportion of survivors continues to increase (a positive outcome), long-term side effects of care will continue to escalate, leading to an increase in chronic noncancer but treatment-related financial and medical issues. ^, The Kline article proposed a risk-based model to optimize post-treatment care to the site most clinically appropriate for that care, and potentially delivered at a lower cost, such as the active incorporation of a primary care provider into the model. Future employment and insurability issues for those who have had cancer continue and are subject to local, regional, and federal regulatory changes. The looming threat of recurrence likely never disappears but certainly remains an emotional burden for a long time and is very disease dependent. Moreover, some treatments may actually predispose individuals to other cancers, further increasing long-term concerns. Adolescents who have survived cancer carry this burden for the rest of their lives. While this is shared with diseases such as diabetes, heart disease, chronic lung disease, and arthritis, the rapid increase in the costs associated with cancer has recently received much attention.

Magnitude of the Issue

In any discussion about costs, one must decide whether the focus is on total societal costs of care (usually difficult to measure), payer costs (usually easiest to measure as the payments to providers and applicable to those patients with some sort of coverage), provider costs (extremely variable, unique to the provider, and usually estimated from charges to reimbursement), patient-borne costs (relevant to insured and uninsured patients), and those costs not captured by classical reimbursement systems, such as travel expenses and out-of-pocket expenditures (very difficult to capture). Nonetheless, when reported, and regardless of the above variable definitions, all have shown a significant increase in cancer costs, especially over the last decade, from $124.57 billion in 2010 to between $186.59 billion and $206.59 billion estimated for 2020. These estimates are based on both incidence and survival trends. There is no evidence that the increase in costs will change in the near future, and most projections are that the rate of increase will also increase with the explosion of new technology and drugs. The cost associated with the initial year of treatment has grown by 19.4% in that time frame, while the cost in the last year of life has grown by 28.3%. The increasing role of continuing care (between the two endpoints) is shown by an increase of 31.6% over the same 10-year period. Not only is cancer being treated more effectively initially, it is increasingly a chronic disease with treatment extended over a longer period of time (similar to the diseases above). Furthermore, relapses that occur between the initial and last year of life have increasing options available to bring the disease back under control, contributing to longer survival after relapse. The average initial year of cancer treatment varies by disease from $5000 for most confined melanomas to $115,000 for brain tumors, ranging from a few hundred dollars a year to $11,000 for pancreatic cancer but these are averages and obviously very stage dependent. However, this group of costs is most likely to continue to increase as the periods of “maintenance” therapy expand for most cancers. The last year of life also varies by disease but ranges from $56,000 for melanoma to $135,000 for brain tumors. Much of this care is palliative in nature, some in intensive care units, and a majority in the hospital. Efforts to reduce these latter figures have thus far been unsuccessful, despite the increase in palliative care units and hospice locations. End-of-life care remains a considerable cultural issue and is relatively unique to the United States.

Given the lag in tabulation, most of the cited data are either 5–10 years old or rely on projections based on newer treatments. In a recent study released by the American Association of Cancer Research (AACR), projections are for cancer costs of approximately $450 billion by 2030, worldwide. Long-term data and even projections, by their very nature, are becoming subject to extreme variation and based on the utilization of current and newly released treatments, research developments and expectations of results, and population demographics. It is likely that even this projection will be refined long before that date to a much larger number. Medicare, Medicaid, and private payers provide some of the most recent expenditure data available and are generally searchable on the web pages of The National Cancer Institute and the American Cancer Society.