Polls and Policy: Signals or Substance

Costs of cancer care in the United States are projected to rise from $124.6 billion in 2010 to approximately $174 billion in 2020, contributing to an emerging consensus that health care spending is on an unsustainable trajectory. With the annual cost of novel therapies often exceeding twice the US median household income of $50,000, access to quality care for individual patients is threatened. Costs of care can lead to financial distress and even bankruptcy. For the health system as a whole, health care spending consumes a growing proportion of federal and state budgets. Rising costs threaten the viability of public health insurance programs, including Medicare and Medicaid, as well as spending on other social priorities, including cancer research. Controlling costs while improving access to quality care and continuing to support innovation thus poses a critical challenge. In considering this problem, it is important to recognize that concerns over cost and access to health care are not new. These concerns were behind efforts at reform under Presidents Nixon in the 1970s and Clinton in the 1990s. Previous reform efforts have been subject to labels of socialized medicine and branded anti-American. Recent efforts to expand access and control costs under the Affordable Care Act have met the same discord and demagoguery. The US public has long endorsed the concept of health care reform, but it has been divided over the nature of reform and how it should be achieved. Writing in 1984 about the “schizophrenia” of the nation over health care costs, and summarizing multiple public opinion polls from that time, Blendon and Altman explained that although controlling costs was viewed as the number one health care priority for the nation, it was not viewed as a top national priority, compared with unemployment, government spending, defense, and other areas. Furthermore, they found that although Americans were deeply concerned with the rising costs of health care for themselves as individual patients, they were not particularly troubled by rising societal spending on health care, and some favored greater national spending on health. We hope to control costs along with improving access and quality; however, it is not clear that cost control can be achieved without facing hard choices. The proportion of the US gross domestic product spent on health care costs has been steadily rising since the enactment of Medicare in 1965. This rise has been driven by multiple factors, including the growth and development of new technologies, an aging population, increased use of tests and scans, and reimbursement policies for physicians, hospitals, and other providers that incentivize delivery of more services. Although many countries struggle with high costs of health care, the United States is somewhat unique in that we prohibit consideration of cost effectiveness in our public health insurance system. At its inception, Medicare was established with a statutory obligation to cover any care deemed reasonable and necessary, but precisely how this should be defined is the subject of ongoing political debate. In this context, Gogineni et al sought to understand current concerns over health care costs among physicians, patients with cancer, and members of the general public, with a focus on Medicare and potential methods to control Medicare spending. They achieved response rates consistent with expectations in similar populations (at roughly three quarters of eligible patients and 50% of selected oncologists and members of public). Some response bias must be considered when interpreting results, with 50% of patients and oncologists self-identifying as Democrats versus roughly one third identifying as Republicans. Approximately three quarters of respondents agreed that Medicare spending was a substantial national problem, and roughly two thirds thought Medicare spending could be reduced without harming health outcomes. The vast majority of each group felt that both pharmaceutical industry and private health insurance company behaviors contributed to high costs. Roughly 80% of the public and approximately 70% of patients and oncologists also believed that unnecessary treatments contributed to high costs. Not surprisingly, larger differences emerged over the question of excessive physician charges, with approximately 80% of the public, 67% of patients with cancer, and only 19% of oncologists viewing this as an important factor. These data highlight the extent to which multiple stakeholders are concerned about costs of care and suggest that there is consensus on potential to reduce unnecessary health care spending without restricting high-value care. Indeed, this is the premise behind the American Board of Internal Medicine Choosing Wisely campaign, through which the American Society of Clinical Oncology and other specialty organizations have identified practices that should be eliminated to lower costs with no adverse impact on quality (and, in some cases, improvement). The challenge of drawing firm policy conclusions from survey work becomes apparent when considering the question of Medicare adopting reference pricing for cancer drugs. Gogineni et al found that 75% of respondents agreed that Medicare should not pay for more expensive treatments when equally effective alternatives were available. They then argue that this indicates widespread support for reference pricing, in which reimbursement for an intervention is set at the rate of the lowest cost equivalent. One might question why 100% JOURNAL OF CLINICAL ONCOLOGY E D I T O R I A L VOLUME 33 NUMBER 8 MARCH 1