Understanding and Addressing Cancer Care Costs in the United States | Oncology | JAMA Network Open | JAMA Network
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Invited Commentary
Oncology
October 6, 2021

Understanding and Addressing Cancer Care Costs in the United States

Author Affiliations
  • 1Cancer Prevention and Control Program, Fox Chase Cancer Center, Philadelphia, Pennsylvania
  • 2Department of Hematology/Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
JAMA Netw Open. 2021;4(10):e2127964. doi:10.1001/jamanetworkopen.2021.27964

The high cost of providing cancer treatment in the United States is a mounting concern. How to deliver high-quality care to the 16.9 million Americans with a history of cancer while maintaining affordability is a widely debated topic and an area of extensive research. Zaorsky and colleagues1 offer a detailed analysis of the most common and costly medical procedures and services used in a large sample of privately insured patients younger than 65 years with cancer. They estimate that cancer-related spending in 2018 for the 15 most prevalent cancer types was more than $156 billion. When costs were examined by category, medical supplies and nonphysician services (which include chemotherapy drugs) accounted for the largest proportion of spending. Across cancer sites, breast cancer had the greatest total number of services and the highest total spending per year, owing in part to the large number of breast cancer survivors in the population. The costliest cancers were those of the breast, lung, and colorectum.

These findings are consistent with prior estimates of cancer care spending. An analysis of the Surveillance, Epidemiology, and End Results–Medicare database indicated that total spending on medical services and oral prescription drugs was highest for the most common cancer sites, including female breast and lung cancers.2 Given successful advances in treatment, many individuals with cancer are living longer, and some may require treatment for the remainder of their lives. Longer periods of treatment and the rising costs of novel cancer therapies have combined to dramatically increase the financial burden of cancer care. As a result, there is significant interest in identifying optimal approaches to managing costs of cancer care.

For example, the authors’ finding that antineoplastic drugs represented a substantial portion of cancer-related spending highlights the need to address high drug costs3 in any effort to reduce spending growth. One such effort is the Center for Medicare and Medicaid Innovation’s Oncology Care Model, which sets spending targets and provides financial incentives for practices to meet these targets. However, how alternative payment models should address the rapidly rising cost of antineoplastic agents while simultaneously incentivizing efficient care remains widely debated.4 Oncology practices have expressed concerns that, despite adjustments in the Oncology Care Model spending targets to account for underlying temporal trends and practices’ use of novel therapies, drug costs still disproportionately affect their ability to meet spending goals.4 This finding has led some stakeholders to advocate for the use of clinical pathways—that is, prescribing treatments based on details about the cancer type, stage, and other clinical characteristics—as an alternative means by which to address spending on antineoplastic drugs.5 Data suggest that implementing evidence-based clinical pathways can reduce cancer drug spending without compromising clinical outcomes. Other models of oncology care delivery, including patient-centered medical homes and bundled payments, are also being actively explored.6

In tandem with policies to promote value-based cancer care, there is a call to broaden our efforts in cancer prevention.7 Extensive uptake of primary and secondary prevention can lead to a reduction in the burden of cancer, and analyses8 have demonstrated that prevention efforts are cost-effective for several common cancers, such as lung and colon cancers. Indeed, in recognition of the ongoing and substantial burden caused by tobacco-related cancers, the National Cancer Institute launched the Cancer Center Cessation Initiative9 in 2017 to support the implementation of evidence-based smoking cessation resources in clinical encounters and across communities. The use of novel approaches and tools to enhance the delivery of smoking cessation treatment services across large segments of the population and diverse audiences has the potential to improve a number of cancer-related population health indices.

The study by Zaorsky and colleagues1 provides an informative snapshot of cancer care use and spending in a privately insured population, but it also raises additional questions that merit consideration. First, there is likely substantial variability in cancer care use and spending patterns among patients. As appropriate cancer care varies by stage and disease status, it is not surprising that previous studies identified considerable heterogeneity in Medicare spending by these factors.2 As one would expect, spending is higher in the initial year after diagnosis, in the final year of life, and for patients with advanced-stage disease. Given that clinical factors were not available in the study by Zaorsky and colleagues,1 questions remain regarding the areas in which value-based care interventions might be most effective. Second, a greater understanding of the association between patients’ use of cancer care services and their out-of-pocket costs is needed. The areas that contribute to spending may or may not be the same ones that most affect affordability for patients. Because younger patients are at greater risk of financial hardship after a cancer diagnosis, understanding both spending and affordability in this population is essential.

Finally, another important consideration is ensuring that all individuals have access to high-quality care. Racial and ethnic minority groups and individuals who are uninsured or underinsured are less likely to receive optimal care, which contributes to increasing disparities in clinical outcomes. Despite the fact that the United States spends more on health care than any other country in the world, we have not been successful in achieving optimal health outcomes for all individuals. Numerous stakeholders have offered valuable recommendations on how to improve access and affordability of high-quality care, but the path to the actualization of a high-performing health care system is complex and will require a national commitment to transforming how we support and pay for such care.

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Article Information

Published: October 6, 2021. doi:10.1001/jamanetworkopen.2021.27964

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Fang CY et al. JAMA Network Open.

Corresponding Author: Carolyn Y. Fang, PhD, Cancer Prevention and Control Program, Fox Chase Cancer Center, 333 Cottman Ave, Philadelphia, PA 19111 (carolyn.fang@fccc.edu).

Conflict of Interest Disclosures: None reported.

References
1.
Zaorsky  NG, Khunsriraksakul  C, Acri  SL,  et al.  Medical service use and charges for cancer care in 2018 for privately insured patients younger than 65 years in the United States.   JAMA Netw Open. 2021;4(10):e2127784. doi:10.1001/jamanetworkopen.2021.27784Google Scholar
2.
Mariotto  AB, Enewold  L, Zhao  J, Zeruto  CA, Yabroff  KR.  Medical care costs associated with cancer survivorship in the United States.   Cancer Epidemiol Biomarkers Prev. 2020;29(7):1304-1312. doi:10.1158/1055-9965.EPI-19-1534 PubMedGoogle ScholarCrossref
3.
Hong  SJ, Li  EC, Matusiak  LM, Schumock  GT.  Spending on antineoplastic agents in the United States, 2011 to 2016.   J Oncol Pract. 2018;14(11):JOP1800069. doi:10.1200/JOP.18.00069 PubMedGoogle Scholar
4.
Lyss  AJ, Supalla  SN, Schleicher  SM.  The Oncology Care Model—why it works and why it could work better: accounting for novel therapies in value-based payment.   JAMA Oncol. 2020;6(8):1161-1162. doi:10.1001/jamaoncol.2019.4385 PubMedGoogle ScholarCrossref
5.
Hertler  A, Chau  S, Khetarpal  R,  et al.  Utilization of clinical pathways can reduce drug spend within the Oncology Care Model.   JCO Oncol Pract. 2020;16(5):e456-e463. doi:10.1200/JOP.19.00753 PubMedGoogle ScholarCrossref
6.
Aviki  EM, Schleicher  SM, Mullangi  S, Matsoukas  K, Korenstein  D.  Alternative payment and care-delivery models in oncology: a systematic review.   Cancer. 2018;124(16):3293-3306. doi:10.1002/cncr.31367 PubMedGoogle ScholarCrossref
7.
Emmons  KM, Colditz  GA.  Realizing the potential of cancer prevention—the role of implementation science.   N Engl J Med. 2017;376(10):986-990. doi:10.1056/NEJMsb1609101 PubMedGoogle ScholarCrossref
8.
Cadham  CJ, Cao  P, Jayasekera  J,  et al; CISNET-SCALE Collaboration.  Cost-effectiveness of smoking cessation interventions in the lung cancer screening setting: a simulation study.   J Natl Cancer Inst. 2021;113(8):1065-1073. doi:10.1093/jnci/djab002PubMedGoogle ScholarCrossref
9.
D’Angelo  H, Rolland  B, Adsit  R,  et al.  Tobacco treatment program implementation at NCI Cancer Centers: Progress of the NCI Cancer Moonshot-Funded Cancer Center Cessation Initiative.   Cancer Prev Res (Phila). 2019;12(11):735-740. doi:10.1158/1940-6207.CAPR-19-0182PubMedGoogle ScholarCrossref
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