The Health Economics of Palliative Care

Payne, Coyne, and Smith present a concise review of thesurprisingly meager literature regarding costs of end-of-life cancer care, anissue with substantial ethical and financial implications. They present evidencethat improved coordination of care holds the potential to lower costs, or atleast to offer better services at the same cost. The authors are to be commendedfor pursuing more rigorous studies regarding this difficult-to-quantify area ofmedical and social services. Moreover, they appropriately highlight thedifficulties in attempting to capture direct costs of medical care and the farmore elusive indirect costs.

While we applaud the authors’ review and their ongoing work, they devotemeager attention to the biggest problem encountered by proponents of medicalcost containment—physician sabotage. Our own experience is that cost-benefitdata are routinely ignored by practicing physicians, who do so out of ignorance,personal bias, apathy (lack of knowledge), or greed (lack of communitystewardship).[1]

Physician Sabotage

Glaring examples of such sabotage abound, both in curative and palliativetherapy. Probably the best documented example in the radiation oncology field isthe nearly universal practice of protracted, expensive courses of palliativeradiation despite overwhelming evidence from randomized trials showing thatabbreviated courses are equally effective.[2]

Similarly, research like that of Payne and colleagues frequently uncovers thepotential for substantial cost savings by modifying current medical practices,with equivalent or improved outcomes. These studies show that dedicatedpalliative care organizations—hospice, nursing homes, and nurse case managedhome care—offer more economical alternatives. But getting physicians to act onsuch findings is another matter.

Working in the confines of the Department of Veterans Affairs (VA) budget, wehave found it easy to document excessive spending for medical care that has beenamply described in the medical literature as unnecessary. Tralins andcolleagues, for instance, identified rampant overuse of prostate cancer work-uptests and follow-up visits in the VA, which continues despite efforts toidentify and curtail it.[3-5]

Managed Care—Our Only Hope?

In a fee-for-service system, physicians’ tendency to maximize interventions(and reimbursements), along with patients’ assumption that more is better, isfueling the runaway medical costs that the United States is again facing. Ourown unfortunate conclusion, from watching and contributing to the literatureregarding the cost of cancer care, is that managed care offers our only hope tostem the unjustified use of medical resources—physicians simply won’t do itspontaneously. And the government is not very good at it, largely because it isso slow to respond to constantly evolving medical evidence regarding treatmentefficacy and newer therapies. While it is true that managed care organizationsmay err on the side of parsimony, we suspect that fee-for-service physicians errfar more on the side of unnecessary care that inflates medical costs.

Physicians are understandably glad to see managed care taking its lumpscurrently.[6] But citizens concerned about the limited availability of qualityhealth care at affordable prices should hope that managed care weathers thegrowing assaults, albeit with legal safeguards against medically unwisepractices.

References:

1. Wallner KE: SmartMedicine: How to Cut Medical Costs and Cure Cancer.Seattle, SmartMedicine Press, 2000.

2. Ben-Josef E, Shamsa F, Williams AO, et al: Radiotherapeuticmanagement of osseous metastases: A survey of current patterns of care. Int JRadiat Oncol Biol Phys 40:915-921, 1998.

3. Tralins K, Wallner KE: Follow-up costs after external beam irradiation forlow risk prostate cancer. Int J Radiat Oncol Biol Phys 44:323-326, 1999.

4. Tralins K, Wallner KE: Excessive work-up costs for early stage prostatecancer. Managed Care Cancer Sept/Oct, 2000.

5. Schwartz D, Billingsley K, Wallner K: Follow-up care for cancer: Makingthe benefits equal the cost. Oncology 14:1493-1505, 2000.

6. Robinson JC: The end of managed care. JAMA 285:2622-2628, 2001.