Opinion

One-Size-Fits-All Cost-Based Formulas: Rationing Care for Cancer Patients

There’s a little-known group out there that just made several disappointing recommendations for all those living with prostate cancer. Sadly, it could mean the difference between life or death for many.

As the nonprofit organization whose mission is educating and advocating on behalf of men, boys and their families to enhance overall long-term health and wellness, Men’s Health Network believes it is in the best interest of our constituents to provide perspective on these upcoming guidelines.

The organization releasing these economic models to assess prostate cancer treatment is the Institute for Clinical and Economic Review. This is a private, self-governing organization established in 2006 to make recommendations to health care insurers, physicians and others about the value of covering prescription drugs and other treatments across the entire health system continuum.

ICER, as do similar organizations, uses a “value framework” based on the cost of a treatment and a mathematical formula that determines what ICER deems a person to be “worth.” The idea is to optimally manage, and look to reduce, health care expenditures.

In our view, this is a very generalized approach to treatment that doesn’t reflect the unique clinical and social circumstances of individual patients. Most importantly, this one-size-fits-all approach will likely result in a percentage of patients not having access to treatments that could save their life or extend their quality of life.

The formula used to calculate a person’s worth is mainly based on age, disease and treatment options in the market. Based on those factors alone, ICER has come up with a price threshold that establishes how much health insurers should cover per year for people who live with a disease, including prostate cancer. It’s called a “quality-adjusted life year,” which assigns a formula-driven value to someone’s life, and this is compared to potential values of various treatments.

These models often become the bedrock of third-party payer decisions and eliminate the shared patient-caregiver decision-making. All too often, these economic models are taken as gospel, not guidance.

ICER assured us it would incorporate patient perspectives into the formula and final report, and while it did so, these were overshadowed and virtually negated by giving such dominant weights to product cost and budget impact.

Prostate cancer — like many diseases — relies on continual technological progress and specialty medications to keep it in check. By ICER’s own admission, these medicines have been proven to delay disease progression and improve survival rates, while maintaining quality of life. That translates into very important human things such as several more years of family time, work time and ability to contribute to the communities to which men belong.

That’s why the Food and Drug Administration approves these innovative therapies, patients prefer them, and clinicians want to use them. In fact, in its draft report, ICER notes that, while some newer treatments haven’t been on the market long, the results are promising, and because of optimized care, they are likely to save money in the long run.

Prostate cancer continues to be one of the leading causes of illness and death among men in America. Because prostate cancer impacts cut a broad swath across men of all racial, socioeconomic and demographic backgrounds, clinical decisions and guidance on these decisions must be flexible enough to properly serve the needs of diverse male populations.

We agree that the cost of health care must be managed, but any method must give equal weight to economics and humanistic needs. ICER would find it unacceptable if patients and caregivers scored the scientific data. Yet their scoring of the humanistic parameters did not include nearly enough data input from those going through the thick and thin of treatment and survival.

We must remember that we are treating people, not numbers.

 

Salvatore J. Giorgianni, B.Sc., Pharm.D., is a science adviser at Men’s Health Network and a chair-emeritus of the American Public Health Association Men’s Health Caucus.

Ana Fadich-Tomšić, MPH, CHES, is vice president at Men’s Health Network and chair of the American Public Health Association Men’s Health Caucus.

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