Many people know Moore’s Law, that the number of transisitors that can be placed inexpensively on an integrated circuit doubles approximately every two years, or the concept that the cost of computer technology decreases steadily as the capabilities increase. For the technology world, the economic model is planned obsolescence: I’m lucky if I can go two years before plunking down money for a new laptop, smart phone, or tablet computer. And it’s amazing to think of how much more I can do with my latest $400 laptop (wifi, color screen, watch movies, play amazing games, do video calls, print wirelessly to a $200 printer) than I could with the Apple IIe that cost $2200 (in 1983 dollars) with the dot matrix printer. Not to mention how much easier it is to carry it around with me.
Sadly, I’m seeing and living a very different and clearly destructive economic model in the pricing of cancer care. Every new drug being released sets a higher bar for cost and poor value. The problem is that, in the US at least, we are almost completely insensitive to the cost of cancer treatments, and pharmaceutical companies are therefore pricing these agents accordingly. Chemo agents have drifted from a few thousand dollars per month to new benchmarks of approximately $10,000 per month for treatments that aren’t curative but confer a prolongation of survival that may hover in the range of 2-4 months. Dendreon’s Provenge (sipuleucel-T), a vaccine-based treatment for prostate cancer that is associated with a median survival benefit of four months, weighs in at $93,000 for the three planned infusions, while Yervoy (ipilumumab), an immune-based therapy for melanoma, confers a similar palliative benefit for $120,000 for the treatment. And those at least offer a survival benefit. Companies providing a “supportive care” therapy that reduces the risk of nausea, or skeletal fractures from bone metastases have also found that they can escalate the cost of their drugs to hundreds or even thousands of dollars per treatment cycle (typically around 3 weeks) without enough resistance to incentivize them to provide meaningful value over what preceded them. Beat the current standard of care marginally and double the cost: what will people do? Not pay? Hell, no…it’s cancer, so the health care system has to pay, no matter what the cost or lack of value.
Of course, this is completely unsustainable, and the US economy is being crushed under the weight of ever-escalating cost of health care, with cancer care the leading area where costs just keep accelerating. Patients and caregivers are also motivated to receive everything with evidence to support it, and many also seek commercially available approaches that aren’t supported by evidence, and without needing to pay a significant proportion have little reason to pursue less than everything possible. Physicians and institutions are financially incentivized to provide as much care as possible, including everything that is indicated by good evidence, and also many things that aren’t but can be covered by insurers. Pharma and medical device companies are delighted that nobody has the ability to challenge the costs of these interventions, lest someone shout “health care rationing!” any time someone suggests that it might be appropriate to ask whether paying any amount in the world for a marginally useful treatment might not be a reason to bankrupt the country. And insurers don’t want to be featured in the media as bad guys not willing to pay $200,000 for a bone marrow transplant — even if it’s in a situation in which there isn’t any evidence it’s helpful. It makes a good story to show a poor young woman with a bad cancer, and a face on the nice patient is far more compelling than someone talking about the costs from a faceless insurance company…
I would argue that there is no setting in which we get less for our money, by a system in which all principal stakeholders (pharma companies, patients, caregivers, doctors, health care administrators) have unfathomable biases and conflicts of interest, and in which the general public is less able to make rational decisions, than in cancer care. We’re all out at a massive dinner together where the check is being split, so everyone wants to ensure that they get not only a dinner but two extra appetizers, a fancy bottle of wine, two desserts, and a $200 glass of port afterward. After all, who wants to be the sucker who ordered soup and then still has to pay an equal share? But people can’t connect the dots between the mindset that “everyone should have every treatment for everything, forever” and the fact that companies are being ruined because they can’t afford the costs of health care, and household budgets are being ravaged because those insane costs paid by insurance companies are being passed right back on to the people being covered.
This feels like someone is just pressing the accelerator as we speed faster and faster into a wall. Unless the US population fundamentally changes the presumption that rationing of care and a testing of value are complete anathema, the cost of health care, with cancer leading the way, will do nothing short of ruin us.