Dr. Jack Kevorkian
Lowell Schnipper, the chairman of the ASCO Value Framework Task Force was also part of a group that supported Dr. Jack Kevorkian and pushed to legalize physician-assisted suicide.
It raises the question: Does the Value Framework recycle the arguments and assertions Dr. Schnipper made in pushing euthanasia as an option for cancer patients in determining how to value drugs and why?
To my mind, it does.
Schnipper, who is also Chief of Hematology/Oncology at Beth Israel Deaconess Medical Center in Boston, has been a driving force in making ASCO focus on the costs and value of cancer care. His support of Kevorkian and assisted suicide legislation are relevant. Specifically, just as Schnipper believed that hastening death when further treatment could only add a few months of life was legitimate, the Task Force he leads asserts that a few months or weeks of life have no clinical value and that further treatment is a waste of money at that point.
Background
In 1998 Schnipper was part of “a high-powered collection of area doctors, academics and lawyers has been meeting privately, working to draft a model bill allowing physician-assisted suicide. "We'd like to get this bill introduced in Massachusetts and elsewhere," says Boston College law professor Charles H. Baron.
The group includes James Vorenberg, former dean of Harvard Law School; Judy Johnson, associate general counsel at the New England Medical Center; Dr. Lowell Schnipper, chief of oncology at Beth Israel Hospital; and Dr. Sydney Wanzer of the Harvard Law School health services. Most of the 10 members, says Baron, support legalization "in the hopes that this will make relief from suffering more readily available and in a less discriminatory fashion and with greater patient autonomy."
Schnipper’s Working Group Supported Dr. Jack Kevorkian
Dr. Wanzer noted: "If Dr. Kevorkian does it a little outside the niceties of proper practice, I can't condemn him for that. If I do this privately and quietly and discreetly, it doesn't force the issue. But he does. I think it's a good combination of the quiet people who go ahead and do what they think is right and the Dr. Kevorkians who do it more flamboyantly."
"Kevorkian is a result of failures of our medical system in caring for someone with intractable or chronic problems," says Dr. Lowell Schnipper, chief of cancer treatment at Boston's Beth Israel Deaconess Medical Center. "But Kevorkian is becoming more and more marginalized as legitimate groups begin to weigh in with the resources and sensitivities the problem demands, which to me is good news."
Schnipper also described hastening death as "consistent with the highest goals of the physician as healer and must be an option in a pluralistic society."
Today Schnipper Believes Cancer Treatment That Adds ‘Only’ Three Months of Life is Not Worth It.
In 2010 Schnipper was the lead author of an article that argued:
“Patients' high expectations of cancer therapy may be another cost driver
In a culture that favors treatment and has an overly optimistic view of what medicine can offer, it is an uphill battle for cost-conscious oncologists to communicate the true value of various forms of therapies, particularly when curative treatment options are lacking.”
He also notes:
“This problem may be particularly American one; other cultures do not seem to view the postponement of death by a few months as holding an equivalent importance. Culturally, are we entirely honest in our assessment of what a few months, particularly spent in illness, can accomplish?”
Value Framework Also Embraces Notion That A Few Months More Of Life Is Not Worth It
Schnipper, writing for the Task Force concludes:
“Cancer drug spending is being driven by “sometimes unrealistic patient and family expectations that lead clinicians to offer or recommend some of these services, despite the lack of supporting evidence of utility or benefit.”
Patients “ also overestimate the benefits of treatments that sometimes extend life by only weeks or months or not at all.
Schnipper Established A Cut Off Point For Value Measured By a 20 percent increase (3 months) in yearly survival
Over the past two decades Schnipper has advanced an economic argument for cutting off cancer treatments. Initially, he maintained that survival time should be increased beyond a specified amount of time:
“On average they (cancer treatments) may delay death for only a very short time, for example 3 months. Although some patients may live for more than 3 months, others will not necessarily live even that long. The drug only slows the progression of the patient's cancer by a few months; it does not “cure” the cancer. The psychological force of the rule of rescue should be much weaker in the context of this cancer care than in mine collapses. It should not make it impossible to resist providing the treatment, and certainly does not justify doing so. “ (In this regard, applying Schnipper's logic to everyone means stopping treatment for every patient that does not gain more than 3 months on average, including babies, HIV patients and children with rare diseases. )
The Task Force Cutoff for Value Is The Same As Schnipper’s
Under his leadership of the Value Task Force, the 3 month cut off was turned in to a specific increase in survival as a percentage of a year of life: “It was generally agreed that relative improvements in median overall survival of at least 20% are necessary to define a clinically meaningful improvement in outcome. “ On average, 20 percent ranges from weeks to a few months. This is a value judgment that applies to all patients with all forms of cancers with all different tumor types.
Schnipper believes that below a certain increase in survival money spent on dying cancer patients should be spent elsewhere to ensure resources are distribution ‘fairly.’
He claims: “The result of abandoning reasonable value standards in the face of urgency would be the use of much very high-cost, marginal-benefit care for dying patients. This situation is arguably our current practice in much care, including cancer care, of dying patients. But it is neither a rational nor ethical use of limited resources. The money spent on this very expensive, but marginal benefit, end-of-life care, could produce greater benefits if spent elsewhere either within or outside the health care system.
Schnipper goes on to state a cut off level:
“A cancer treatment that postpones death on average for 3 months at a cost of $100,000 does not produce…a large benefit. The opportunity costs of securing that treatment are much too great.”
Schnipper has argued that spending on overage increase of three months comes at the expense of other uses of money.
“A life-saving treatment like an appendectomy generally produces a very large benefit; it prevents the patient's death and returns him or her to a healthy life. But a cancer treatment that postpones death on average for 3 months at a cost of $100,000 does not produce such a large benefit. The life extension is short, and the quality of life during it is often poor. It is not a large enough benefit to trump the greater benefits to many that would have to be foregone to provide it.”
Similarly, the Value Framework declares:
“Oncologists should be aware of the value of an intervention in terms of societal cost. Clearly, increasing health care costs are eventually transferred to the consumers of health care, if not in the form of out-of-pocket costs, then in the form of higher insurance premiums, higher taxes, or limited wage increases as employers confront the escalating costs of providing health care to their employees."
What Schnipper and The Task Force Ignore
The task force asserts that spending on new cancer drugs bankrupts individuals and our healthcare system. But the benefits to patients are palpable. Drugs that emancipate our immune system to attack tumors or target specific genetic cancer causing mutations have transformed cancer care. These cancer drugs are expensive no doubt. Yet they account for only account for 0.7 percent of the $2.9 trillion we spend on health care. Cancer spending has increased in 1995 from $42 billion to about $130 billion today. But its share of total health spending declined from 4.7 percent to 4.4 percent during the same time period.
New medicines reduce the cost incurred by a cancer diagnosis, for instance in part by reducing hospitalization. In 1996 drugs were 3.7 percent of cancer spending and 62.4 percent went to hospitalization. By 2012, drug spending was 9.3 percent of cancer costs while the share going to hospital stays dropped to 41.3 percent. If we were allocating the same proportion of money to hospitals today, as we were in 1996, we’d be spending about $18 billion more a year on cancer. And we have yet to see the full benefit of the cancer drugs not yet included in these estimates.
As the price and number of new treatments increases, their value increases too. A recent Bureau of Economic Analysis study found between 2000-2010 that “medical technology (for treating cancer and other costly illnesses) is improving over time, leading to better health outcomes at a lower cost per patient.” A lot of that has to do with medicines displacing less effective and more costly oncology services. Why does the ASCO Value Task Force ignore that.
Conclusion
Between the time Schnipper was pushing for assisted suicide until the time that he has begun pushing to limit the use of cancer drugs for people with “only” three months to live cancer survivorship has surged from 10 million to 14 million people and life span expressed by 36 million life years worth about $3 trillion.
If Schnipper’s vision had become common practice how many of those survivors would not be alive today? How many will not live because of his current plans?
