Introduction
There is a perception among oncologists that the field of global oncology pertains
only to matters related to low- and middle-income countries (LMICs). It stems from
a perception that considers lack of access to cancer care and unaffordability of therapy
as problems that plague the less affluent regions of the world. In this commentary,
we aim to shed light on the fact that these issues do not respect the dichotomies
of high-income versus low-income countries or the global north versus south.
When physicians from high-income countries were surveyed about the access to cancer
medicines deemed essential by the World Health Organization, a large majority of them
felt that these medicines, including immunotherapy, were universally accessible (i.e.,
no substantial out-of-pocket expense for >90% of patients).[1] Unfortunately, the inaccessibility and unaffordability of cancer care are profound
even in high-income countries, although we perceive it as otherwise. This inaccurate
fact stated by practicing oncologists makes it clear that their current understanding
of the accessibility and affordability of cancer care as oncologists is faulty.
Almost 27 million (8.6%) Americans were still uninsured in 2016.[2] A large proportion of cancer survivors experience financial hardships due to cancer.[3] Even if we falsely assume that the out-of-pocket expense for the individual is marginal,
the economic burden of cancer care is steadily rising. It is definitely not sustainable
for the economy in the long run.
The US Healthcare System: An Eagle's Eye View
The US Healthcare System: An Eagle's Eye View
In the United States, the government provides two types of health coverage for patients
under the supervision of the Center for Medicare and Medicaid Services (CMS). Medicare
for patients more than 65 years of age and Medicaid for the disabled. Most private
and public sector employers provide health insurance as part of the employee benefits.[4] A private health insurance coverage can be bought for a monthly fee from the marketplace
for the self-employed. Health insurance does not cover all healthcare expenses (referred
to as “cost-sharing”). Health insurance would start covering the costs after an initial
“deductible” is being met by the patient, which can be ranging from hundred to a few
thousand dollars depending on the plan. Then, once the patient goes for a doctor visit,
he/she may have to pay a small fee (referred to as co-pay) at the respective offices,
usually about 25 to 100 dollars.
Even after the patient meets the deductible, most insurance plans pay only a part
of the cost, ranging from 60 to 80%. The patient has to pay the remainder of the price
(“co-insurance”). All these costs are covered by the patient account for the “out-of-pocket-maximum,”
which is usually in the order of a few thousand dollars. Once the patient meets the
“out-of-pocket- maximum,” the subscribed health insurance plan usually covers the
remainder of the cost. The “Donut hole” is the gap in insurance coverage when a patient
is responsible for the cost of the drugs after an initial period where the plan pays
for the medications. If the patient is “uninsured” or “self-paid,” they have to depend
on the safety net hospitals that may provide some financial assistance.
Pharmaceutical benefits managers (PBMs) manage the prescription drug benefits for
private insurers and government health plans.[5] Even though the PBMs were introduced to decrease the cost of prescription medicines,
in reality, they work as a middleman, leading to increased cost of drugs, lower value,
and increased administrative burden.
The Three-Legged Problem
We can categorize the problems in the American healthcare system into three major
parts.
First, it is inaccessible. The inaccessibility of cancer care can be due to multiple
reasons—regional, geographic, ethnic, racial, or socioeconomic disparities. For instance,
the survival of breast cancer patients is adversely affected by where they live; patients
who live in poorer neighborhoods have reported decreased survival rates.[6] The racial disparities, Black, Hispanic, and Native American patients have more
inadequate access to cancer care and consequently reported worse survival rates, have
been well established in multiple cancers, including prostate cancer,[7]
[8] cervical cancer,[9] and head and neck cancers.[10] Geographical disparities in cancer care have been well documented in various cancers,
including breast cancer, colon cancer, and prostate cancer.[11]
[12] For instance, geographical differences and socioeconomic deprivation lead to late-stage
diagnosis and worse survival in colon cancer.[13] Unfortunately, all of these disparities work hand-in-hand to make timely cancer
care inaccessible to the most vulnerable population.
Second, it is unaffordable. Financial toxicity in cancer care is defined as the harmful
personal financial burden faced by patients receiving cancer care.[4] Catastrophic health expenditure refers to any medical expense that can threaten
the household's financial stability.[14] One in three Americans experiences financial burden as a result of medical care.[15] The risk of a high financial burden is significantly greater in patients with cancer
than patients with other chronic medical conditions.[16] Thirteen percent of the nonelderly patients with cancer spend at least 20% of their
income, and 50% of the elderly (Medicare beneficiaries) spend at least 10% of their
income on cancer treatment-related out-of-pocket expenses.[16]
[17] Patients with cancer had a nearly threefold more significant risk of declaring personal
bankruptcy. Those bankrupt patients had a 79% higher mortality risk than those who
did not.[15]
[18] Zafar et al explained the three possible reasons behind the relationship between
financial distress and a higher risk of mortality[15]: poorer subjective well-being,[19] impaired health-related quality of life,[20] and subpar quality of care.[21]
Finally, it is unsustainable. The US healthcare expenditure is almost 3 trillion dollars/year
(almost equal to the gross domestic product [GDP] of India in 2021).[22] It is nearly identical to 18% of the GDP of the United States. The cost of healthcare
is rising year by year. Cancer care costs are estimated to grow by 34 to 246 billion
dollars by 2030.[23] It is unsustainable for the country's economy.
Contributing Factors for Financial Toxicity
Contributing Factors for Financial Toxicity
Multiple factors contribute to financial toxicity in the United States ([Table 1]). Unnecessary use of diagnostic testing leads to wastage of almost 210 billion dollars
per year.[24] Overdiagnosis (when a condition is diagnosed that would otherwise not go on to cause
symptoms or death during a patient's lifetime) and overtreatment (when medical services
are provided with a higher volume or cost than appropriate) are also pervasive problems.[25]
[26] It is estimated that up to 30% of the US healthcare cost is wasted money.[27] The use of low-value practices, including the injudicious use of expensive treatment
modalities that offer a marginal benefit at best, also leads to substantial financial
toxicity. A lack of pricing competition and choice also leads to increased cost of
healthcare products and technologies.[28] The CMS is banned from negotiating drug prices which affects the medication cost
for millions of Americans. A study that reviewed the cost of cancer medicines (e.g.,
rituximab and bevacizumab) found that Americans are paying almost twice the price
compared with Norway, likely due to the lack of negotiating power for CMS.[28] The high cost of innovative therapeutic techniques is also a contributing factor,
especially when used in terminal disease.[28] The use of more extended course radiation treatment and indiscriminate use of proton
therapy may also contribute to financial toxicity.[29] Another cause is the excess burden of billing and insurance-related administrative
cost—both by the insurer and the provider. It was estimated by a recent study in 2017
by Woolhandler and Himmelstein that the United States spends 1.1 trillion dollars
on administrative costs, which is almost one-third of the healthcare expenditure.[30]
Table 1
Contributing factors for financial toxicity in the United States
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1. Overdiagnosis
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2. Overtreatment
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3. Unnecessary use of diagnostic testing
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4. Use of low value practices
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5. Injudicious use of expensive treatment modalities
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6. Lack of pricing competition and choice
|
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7. High price of innovative therapeutic techniques
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8. Use of extended course radiation treatment and indiscriminate use of proton therapy
|
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9. Excess burden of billing and insurance-related administrative cost
|
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10. Lack of awareness of the cost among physicians and the patients
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11. Lack of price transparency
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Lack of awareness of the cost of various therapies contributes tremendously to financial
toxicity. Significant numbers of physicians in the United States believe that cancer
care is accessible and affordable to the whole population, but in reality, it is not.[1] Physicians' knowledge about the cost of diagnostic tests, medicines, or healthcare
visits is poor.[31] It was found that when the data on the fees were provided to the physicians, they
cut down the use of ordering tests.[32] So, it is crucial to educate the physician community about this cost of healthcare.
Another pervasive problem pertains to the lack of price transparency. It is challenging
for patients to determine how much a medical intervention will cost them. Sadly, even
physicians are in the same boat.
Solutions
The Institute of Medicine in the United States has called for attention to the “waste
in healthcare” and came up with suggestions to provide “best care at lower cost” in
2013.[33] “Choosing wisely” campaign has been initiated as a part of this effort to curtail
the use of low-value practices and thereby to decrease the cost of health care.[27] Various organizations of physicians involved in cancer care, like the American Society
of Clinical Oncology and the American Society of Radiation Oncology, have come forward
with their recommendations to help in this regard.[27]
[34] These efforts may have improved the awareness of low-value practices among oncologists;
but there is no definitive evidence that these have successfully curtailed the cost.
Having the influence and power for negotiation curtails the cost of drugs to some
extent.[35] There have been some efforts to control prescription drug pricing, but more efforts
are needed at a policy level.[36] Recently, there has been an effort to have online pharmacies that can cut the cost
for the patients (e.g., the cost-plus drug company). We believe this will result in
competitive pricing among the various PBMs. The medical community and policymakers
are having more discussions about the lack of price transparency.[37] Allowing CMS to have the power for price negotiation will help curtail the cost
of drugs. At the level of physicians and patients, education efforts are needed to
improve the awareness of the problem and the potential solutions.[32]
Take a Leaf Out of the Indian Scene
Take a Leaf Out of the Indian Scene
Cancer care in India is burdened by financial toxicity, much more than in the United
States.[14] There are multiple reasons for this, including the lack of insurance, poverty, and
lesser spending by the government on healthcare. It is often suggested that the average
Indian middle-class family is one medical bill away from poverty. But there are some
silver linings in India; there are multiple options for generics and biosimilar drugs,
which have helped decrease the cost for the patients.[38] For instance, Nair et al reported that the availability of rituximab biosimilars
in India tremendously cuts costs, leading to increased access to this life-saving
therapy (35% in 2010 to 95% in 2020).[38] Greater access to generics and biosimilars can help reduce the price of cancer therapy
in the United States, with no detrimental impact on outcomes.
Conclusion
There are critical challenges to delivering cost-sensitive cancer care in high-income
countries. Understanding the issues and applying best practices in other parts of
the world would help address some pervasive problems. We believe that such bidirectional
learning would improve patient care and exemplify the true meaning of global oncology.
