The Lynx Group

Economics Impede Growth of Supportive Care Services

September 2012, Vol 3, No 6

New York, NY—Supportive care is effective in improving outcomes, but the growth of supportive care programs is hampered by economics, explained Eduardo Bruera, MD, Chair, Palliative Care & Rehabilitation Medicine, University of Texas M.D. Anderson Cancer Center, Houston, speaking at the 2012 Multinational Association of Supportive Care in Cancer International Symposium. “Financial distress is a huge elephant in the room,” Dr Bruera stated.

More studies are needed to demonstrate dollar savings achieved by supportive care, but the optimal design of these studies is not clear. Direct costs and revenues have been identified, but the savings achieved by supportive care are not well known, Dr Bruera told the audience. Research in supportive care needs to be independent, so that the design of studies does not lead to bias.

The Economic Analysis Conundrum

“Some misconceptions related to economic analyses are that ‘cost-effective’ means cost-saving, low cost is economically attractive, large cost is economically unattractive, and that preventive therapies save money,” Dr Bruera commented.

The ideal design of studies to show cost-effectiveness of supportive care could include several outcomes—cost per life saved, cost per death averted, and reduction in symptom domains. The less expensive supportive care program may not turn out to be the best approach from an economic point of view. “A cheaper program could end up costing more in healthcare resource utilization in the end,” Dr Bruera stated.

Other considerations in demonstrating economic benefits include cost-utility analysis, outcomes, refractory symptoms requiring sedation, and hospitalization.

A cost-benefit analysis measures costs and health outcomes by assigning a dollar value to someone’s life or to symptoms.

Economic analyses should include the perspectives for the analysis (ie, society, the patient, and the institution), the rationale for costs included in the analysis, a description of the benefits and harms, discounting if costs and benefits accrue during different periods, an incremental cost analysis, and a sensitivity analysis.

When supportive care is initiated early, clinical outcomes are improved, which is economically attractive for payers, such as hospitals, health plans, and government agencies.

“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,” Dr Bruera noted.

Need for Comprehensive Inpatient Supportive Care Program

Dr Bruera emphasized that the environment in which supportive care is delivered is place-specific, and what works in one setting may not be a good fit in another. M.D. Anderson Cancer Center, where he works, is the only comprehensive inpatient supportive care program in the United States, he said.

In general, the environment in comprehensive cancer centers is more favorable for supportive care clinics than in noncomprehensive cancer centers. A recent survey suggested that approximately 50% of comprehensive cancer centers plan to increase supportive care services compared with 25% of noncomprehensive cancer centers.

In the United States, payment for services is being increasingly linked
to outcomes. The National Quality Forum recently identified 4 important outcomes related to payment—intensive care unit deaths, reduced admissions to the emergency department in the past 30 days, chemotherapy administered ≤14 days before death, and a reduction of overall payment.

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