NCCN, like the American Society for Clinical Oncology (ASCO) has create a framework telling doctors and patients that in selecting treatments some medicines are worth more than others.
NCCN, like ASCO, claims choosing which medicines are most affordable will address “the combination of increasingly unsustainable rises in the costs of cancer care, the accelerating pace of expensive innovations in oncology, and persistent hope for rescue in patients with life-threatening disease.” Apparently, persistent hope is something we should discourage because saving a few dollars is more important.
However, the assertion that cancer costs are unsustainable is untrue. New 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.
In fact, 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 hospitalization dropped to 41.3 percent. During the same time period the life of expectancy of cancer patients increased, mortality rates declined by 20 percent and the number of cancer survivorship grew from 9.8 million to 13 million. The NCCN flashcards ignore these cost and life saving gains.
To be sure, the out of pocket cost of cancer drugs has increased. But the huge jump is caused by insurers and pharmacy benefit managers who force patients to pay up to 40 percent of the cost of a drug that two years only cost a few dollars a month. More recently, the percentage of health plans placing all drugs in the highest cost sharing tier has nearly doubled.
Capping cost sharing would require about people paying 50 cents more in premiums every month. Yet NCCN accepts insurer cost shifting as a fait accompli. It forces doctors and patients to choose treatments, not based on value, but on the insurer imposed cost of a medicine, a cost that is often based on how big a rebate other medicines generate.
Further, each NCCN flashcard measures one drug for one disease for an average patient. But often drugs must be used in combination to achieve results. Indeed, each “tumor may embody more than 100 different diseases, and multiple subtypes of each tumor exist. Even if some of these tumors have things in common, the individual landscape of each patient may be very distinct.”
Finally, the flashcards are to be used, it seems, to discourage the persistent hope for rescue in patients with life-threatening disease.
Hope is a valuable thing. For example, AZT, the first HIV drug, showed no additional survival in clinical trials. NCCN flashcards would deem them expensive but ineffective. In the real world, the use of such medicines kept enough people alive until the next generation of anti-AIDS extended life by years. The flashcard negates that value.
A survey of patients who chose assisted suicide in Oregon show that since 1998 the number of people citing the cost of care as a reason for their decision jumped 77 percent. To the extent that the NCCN flashcards reinforce the impact of insurer cost shifting and are skewed against persistent hope, they may contribute to an increase in cancer patients thinking there is no longer a reason of a value for living. Let's hope not!