It is well documented that healthcare costs and spending have been growing at staggering rates. Healthcare accounts for ~17% of total gross domestic product (GDP) in the United States. In comparison, in 1960, healthcare only accounted for about 5% of GDP. Our current level of spending is nearly double the average percentage of GDP of every other country in the world. Total healthcare spending comes from many sources, including but not limited to hospital care, physician and clinical services, nursing home care, administrative costs, and prescription drugs. For many decades, spending on prescription drugs contributed only modestly to overall spending growth. The growth of spending on prescription drugs accelerated sharply around 1980, but its relatively small share of total spending at that time limited its effect on total spending. Beginning in the mid-1990s, however, prescription drugs accounted for a much more prominent component of growth in total spending and is currently averaging an increase of ~10% per year. This increase is certainly also being seen in oncology.
On the flip side, cancer death rates have decreased by 1% annually for the past decade. While this is not entirely due to chemotherapeutics, newer drugs have certainly impacted the mortality rate changes for certain cancers and subtypes of cancer. For good or bad, most new agents over the past decade have been more complex in production and/or have had a more expensive development history before getting to market. These differences come with a true price tag. While we previously rarely considered price in treatment decisions in oncology (and for most situations still do not) and did not weigh price versus real efficacy as long as the drug had FDA approval, increasing push from many players in healthcare is changing that. Further, oncology was probably one of the most prominent fields using therapies off label. While off-label usage will continue, the level of evidence required to use drugs outside of the FDA label will need to and should be more scrutinized.
In the search for ways to control the rising percentage of healthcare dollars going to drugs, various models have been developed, including tiered systems of copayments, lists of preferred drugs for a class of agents or disease entity, and more restrictions on types of pharmacies used. Dr Hansen does an excellent job explaining the complexities of pharmacy restrictions and cost shifts. In my own practice, more and more patients tell me that their prescriptions can only go to a certain pharmacy or mail-order place for many of the medications I prescribe. When I grew up in a modest-sized town in New Jersey outside of New York City, my family used a local “ma and pa” pharmacy in town where the pharmacist knew our names, medical histories, and prior medication issues. As discussed in the article, specialty pharmacies are often far from the patient’s home, and communication is often purely electronic or at best by phone. Admittedly, while many patients initially gripe when they are required to use a specialty pharmacy, once they “get the system down” for their own individual plan and pharmacy, some do find it very convenient and seamless.
This is a learning process for all of us, as these types of models to control healthcare costs will continue to expand. As healthcare providers, we need to not only continue to be part of the discussion of these changes but also be part of the solution. Dr Hansen’s conclusion that we need to consider all aspects of value with these expensive drugs is critical. We want to do the best for our patients, though the best is not always just providing another drug to try to help their cancer. While we shun the thought of making decisions based on costs, we do need to balance costs with the potential benefit of a therapy.