Editor’s Opinion: Asking the Hard Questions

  After detailing the costs and describing the potential increases in life expectancy provided by some of the new cancer drugs, the author of a recent Newsweek article concluded that, aside from academics and insurance-company executives, few Americans are willing to consider the “price of time.”¹ Discussions about healthcare cost-effectiveness in general continue to receive, at best, a lukewarm reception from healthcare providers and patients. However, the increasing realization that healthcare represents 17% of Gross Domestic Product (GDP) in the United States² and that system tweaks and bandaids have been unable to curb spending or the increasing financial pressure on individuals may eventually change such (non)thinking.   It has long been believed that “increased spending and the public’s appetite for medical technology will eventually force us to recognize limits more directly and that inevitably we will embrace cost-effectiveness analysis as the best solution to our dilemma.”³ Clearly, there is something very unsettling about debating whether it is appropriate to spend $15,000 for a pancreatic cancer drug treatment that increases life expectancy 14 to 16 days or $120,000 to buy an average of 4 extra months of life if you have advanced melanoma.¹ Many of these drugs are not reimbursed in other industrial countries where coverage decisions generally include an evaluation of costs and benefits. Not so in the United States.

  Newmann³ cited the following factors to explain the resistance to cost-effectiveness analyses in healthcare: 1) lack of understanding about the concept, 2) mistrust of methods and motives, 3) regulatory and legal barriers, and 4) American’s distaste of limits. Although the fact that insurance companies continue to make individual coverage decisions a topic of debate, US programs to align payment with patient outcomes of care have been underway for quite some time now. We are, of course, familiar with the 2008 implementation of nonpayment to hospitals for the occurrence of a list of so-called “never-events”; now, many states have adopted similar measures for persons insured through Medicaid. Also, as of October 1, 2012, hospitals with excess readmission rates will see a reduction in their payments from the Centers for Medicare and Medicaid Services (CMS) (see: https://cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Readmissions-Reduction-Program.html/). Approximately 2,200 hospitals are affected.

  Unlike limits on individual coverage decisions, these measures have not resulted in a public outcry. Few patients will rail against measures designed to improve their care. And therein lies the rub when discussing the cost-effectiveness of individual prevention or treatment measures: By definition, these discussions include the effectiveness of an intervention, but cost is more easily understood, remembered, and talked about. Also, by definition, we are considering using analyses and methods we may or may not trust.³ Yet, in the end, and in every area of healthcare, the question of whether an intervention is worth it will have to be answered through research.^4,5 In our area of practice, we may not be talking about terminal diagnoses, but the preservation of a limb or the ability to function are certainly not easy to discuss in the context of cost or reimbursement limitations — all-the-more reason to embrace cost-effectiveness research and help patients understand that, by definition, this includes a desired outcome of care. My fear is that if we do not embrace the concept of cost-effectiveness, someone, somewhere, will start making reimbursement decisions for us based on costs alone. Better to ask the hard questions and find the answers now than to not have a chance to ask them at all.

 This article was not subject to the Ostomy Wound Management peer-review process.

1. Beil L. How much would you pay for three more months of life? Newsweek. September 3, 2012. Available at: www.thedailybeast.com/newsweek/2012/08/26/the-cancer-breakthroughs-that-cost-too-much-and-do-too-little.html. Accessed September 10, 2012.

2. Fleming C. US health spending projected to grow 5.8% annually. Health Affairs Blog. July 28, 2011. Available at: http://healthaffairs.org/blog/2011/07/28/u-s-health-spending-projected-to-grow-5-8-percent-annually/ Accessed: September 10, 2012.

3. Newmann PJ. Why don’t Americans use cost-effectiveness analysis? Am J Manage Care. 2004;10(5):308–312.

4. Bolton L, Baine WB. Using science to advance wound care practice: lessons from the literature. Ostomy Wound Manage. 2012;58(9):16–31.

5. van Rijswijk L, Gray M. Evidence, research, and clinical practice: a patient-centered framework for progress in wound care. Ostomy Wound Manage. 2011;57(9):26–38.