Health reform raises central ideological questions about the size and scope of government, about progressive taxation, about the individual mandate and more. It’s easy to forget that cost control will be a huge challenge, no matter how these ideological matters are resolved, indeed under any health system. Finding the right combination of humanity and restraint will be particularly hard in addressing life-threatening or life-ending illness. Economic incentives, American culture, a changing doctor-patient relationship and fundamental uncertainties at the boundaries of clinical care conspire against our efforts to provide more humane, more financially prudent care.
The necessity and the difficulty of these tasks were underscored by a beautiful New England Journal of Medicine essay, Bending the Cost Curve in Cancer Care, by Thomas Smith and Bruce Hillner. Their essay received favorable attention from health policy journalists. Yet because it didn’t push the usual partisan buttons, it didn’t receive much wider attention. That’s too bad, because Smith and Hillner raise many issues that apply beyond the realm of advanced cancer care. For instance, they offer a brave model of skilled providers identifying specific opportunities to reduce costs within their own specialties. They also present suggestions to address the burdens imposed by cancer overtreatment and undertreatment on patients and society as a whole.
Their first, deceptively simple recommendation is to target cancer testing and imaging to situations of proven benefit. Measured at the population level, the survival benefits of such imaging — routine mammography screening for asymptomatic young women or early lung cancer screening, for example — are often minimal or unproven. Such imaging is also quite costly. The annual direct costs run into the billions of dollars. Indirect costs include patient anxiety and follow-up treatments that can be expensive and intrusive. And, at the other end of the life spectrum, physicians are performing annual mammograms in patients who have quite limited life expectancy. Providers also implement follow-up scans searching for relapse, such as frequent PET-CT scans, that are not supported by guidelines or by clinical trial evidence.
In part, these problems reflect powerful incentives on providers, device manufacturers, and others which promote aggressive care. The problems go deeper, too.
Dr. Vivek Murthy, president of Doctors for America, e-mails that physicians spend less time with patients (not always for reasons of their own choosing) and are less likely to have important discussions with patients and families about priorities or tradeoffs in care. It takes less time to consent to an intervention or to prescribe a medication than it does to persuade a patient that an intervention or procedure is unwise. Murthy notes that one cumulative effective of millions of missed conversations is to reinforce the intervention mindset among patients. So, alongside efforts to alter physician incentives, medical schools and health care settings must equip physicians with the knowledge, the interpersonal skills and other supports to conduct these important conversations well.
Another problem may be even more challenging. We, the public, display a strong bias toward the most aggressive and costly care, often at the expense of other things. The proliferation of $100 million proton beam cancer facilities, even as basic cancer prevention efforts go unfunded, exemplify the imbalance in urgency and priorities. Continued Medicare reimbursements for costly yet dubious medications such as Avastin for breast cancer raise inevitable questions of cost-effectiveness. Whatever your ideological perspective, Medicare should not and cannot provide a blank check to the supply-side of the medical economy, especially in a political and regulatory context in which private payers are under strong pressure to follow suit.
Smith and Hillner’s essay also raises sensitive issues regarding overly aggressive chemotherapy for patients who face fatal metastatic cancers. Given anxieties captured in the crystalline phrase “death panel,” I would not commence a national cost-control discussion within the frightening and divisive arena of end-of-life care. On the merits, though, Smith and Hillner cite much evidence that both patients and American society would benefit from less toxic and less aggressive care. When further chemotherapy is unlikely to be successful, they suggest that symptom-directed palliative care provides a better treatment course.
Ironically, the inclusion of palliative care elements within standard care may also prolong life. As Atul Gawande noted in the New Yorker, a randomized trial found that metastatic non-small-cell lung cancer patients assigned to early palliative care lived almost three months longer, on average, than their counterparts receiving usual care. The earlier palliative care group experienced higher quality of life, was less likely to display depressive symptoms and was more likely to be spared toxic side-effects of futile therapies. Some imperfectly understood combination of these benefits prolonged survival through provision of more cost-effective, less-punishing care.
Here again, we, the general public, must alter our own mindset to improve the quality of care. Metastatic lung cancer may be the most straightforward case. The majority of patients with this condition die within one year. Inclusion of palliative care and the turn away from further futile therapy are thus most compelling. Even here, though, many families hesitate to embrace palliative care because they regard loss of hope as the entry ticket. A definitive bleak diagnosis should not be required to receive services commonly associated with palliative care. All patients require effective pain management. All patients require open communication about prognosis and, often, advance care directives.
Such discussions aren’t easy, especially when families don’t fully trust the care team. Years ago, my father-in-law was diagnosed with advanced lung cancer. At one point, his doctors discussed the possibility of a punishing thoracic surgery. They were unenthusiastic. Yet our family wasn’t really ready to give up on the prospect of substantially life-prolonging care. Moreover, we weren’t very confident in his doctors. They had done a pretty poor job in the early stages of his care. They lacked the authority to say: “There’s nothing more we can do.”
Fortunately, one of my own physician colleagues mapped the options with me. He explained that surgery was unlikely to prolong my father-in-law’s life and the most likely outcome was that he would spend his few remaining months in recovery from a painful and failed surgery. A different path was chosen. He died soon after, at home, under dignified and humane circumstances in the care of his family and a local hospice.
We all must face these issues to control costs, and for other reasons, too. We can treat our loved ones, and ultimately ourselves, more effectively, more efficiently, and more decently than we often do.