Eduardo Bruera, MD
One of the main challenges in supportive care is economics, explained Eduardo Bruera, MD, in a session at the 2012 MASCC Annual Symposium. Research is needed to justify the dollar savings achieved by a supportive care program, but it is not clear what should be measured and how studies should be designed to demonstrate this, he said.
“Costs and revenues are well known. Savings [achieved by supportive care] are the most important factor in supportive/palliative care and are not well known. That is what makes it hard for supportive care programs to grow,” explained Bruera, chair, Department of Palliative Care and Rehabilitation Medicine, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston.
Disease-related and treatment-related problems in patients with cancer are well known, and more studies are not needed to document these problems, he continued. “We have a large number of tools to evaluate patients’ symptoms, and more studies than we need on this. Financial distress is a huge elephant in the room,” Bruera said.
The main goal of supportive care is to improve symptoms, not to increase survival. Supportive care is effective if instituted early, he continued. Supportive care programs can improve clinical outcomes for patients, and this should be economically attractive for payers, whether the payers are the hospital, insurance system, or government agencies.
“The environment in which supportive care is delivered is highly place-specific. Whatever works for me in my institution may not work for you,” he told attendees. “I am lucky enough to work in the largest medical center in the world, with 160,000 employees. However, MD Anderson operates the only comprehensive inpatient supportive and palliative care program at the Texas Medical Center.”
A random survey conducted in the United States demonstrated that 60% of comprehensive cancer centers had supportive care clinics, while only 22% of noncomprehensive cancer centers had clinics and only 20% of noncomprehensive cancer centers had designated beds for supportive care. About 50% of comprehensive cancer centers plan to increase services compared with 25% of noncomprehensive cancer centers.
“A vast majority of cancer centers will not increase services. The clinical effectiveness of supportive care is proven, but money is the problem. Of all the perceived barriers to developing a supportive program, the main one is money,” Bruera emphasized.
Potential outcomes to demonstrate cost-effectiveness include: cost per life saved; cost per death averted; and reduction in symptom domains. A supportive care program in one institution may be cheaper than in another, but actually may end up costing more in healthcare resources needed because the program is suboptimal. “The cheaper program may in the end cost more,” Bruera noted.
Other considerations in demonstrating economic benefits of supportive care include cost-utility analysis, outcomes, refractory symptoms requiring sedation, and hospitalization.
Economic analyses should include: perspective for the analysis (eg, society, patient, institution); rationale for costs included in the analysis; description of the benefits and harms; discounting of costs and benefits accrued during different periods; incremental cost analysis; and sensitivity analysis.
Some misconceptions related to economic analyses are that cost-effective means cost-saving; that low cost is economically attractive; that large cost is economically unattractive; and that preventive therapies save money, Bruera continued.
Several studies have shown that less money is spent on patients referred to palliative care, Bruera said. Some studies show that costs are reduced in in-patient days and ICU deaths after starting a supportive care program. “This leaves a big pocket of money to spend on supportive care,” he said.
The environment in the United States is changing. Payment is being increasingly linked to outcomes, such as those published by the National Quality Forum: ICU deaths, reduced admission to the emergency room in the last 30 days; chemotherapy given 14 days or less before death; and reduction of overall payment.
“It is difficult to predict results and whether there will be denial of payment for supportive care for individual patients. The cost/benefit of supportive care programs—including the cost of the program, reimbursement, downstream revenue, and downstream savings—needs to aligned. More than the actual dollar value, we are moving to clinical outcomes that will have a dollar value. We are being told what those outcomes are, and we need to develop a way to show savings. But economic studies need to be done in the context of a specific healthcare system,” Bruera said.