Foreign Cancer Care Offers a Mirror to Our Own

May 2010, Vol 1, No 1

Baltimore, MD—In light of ongoing discussions on healthcare and its reform in the United States, an examination of how care is financed and delivered in other parts of the world could provide a useful contrast for our own national deliberations. That was the premise behind a session at the Association of Community Cancer Centers’ (ACCC) 36th Annual Nation al Meeting titled “Treating Cancer in Foreign Healthcare Systems,” which offered an insightful look into the financing and the value systems that undergird the healthcare systems in France, Germany, Italy, the United Kingdom (UK), and other nations around the world.

The panel discussion, moderated by Cliff Goodman, PhD, of the Lewin Group of Falls Church, Va, began with a discussion of how healthcare is financed in other countries. As with those countries, “The way this country’s healthcare financing system is set up trickles down and has a lot of other effects in the way choices are made in cancer care,” said Dr Goodman.

Anne-Pierre Pickaert, MSc, of Kantar Health, described the social construct of healthcare financing in Western Europe. Germany has a social contribution system; Italy, Spain, and the UK have a tax-based system. In France, there “are no hurdles to access” for care, she noted; coverage is universal and publicly funded.

Harris W. Dalrymple, PhD, MML, of the UK-based contract research firm PPD, indicated that Eastern Europe also has a federally funded system of healthcare, but generally speaking, that coverage is capped. “One of the consequences of that capping is that once the funds for treatment are exhausted, the treatment options are exhausted as well,” he noted. “That has implications for access to some of the newer, more expensive cancer therapies.”

In Canada, said Carol Sawka, MD, FRCPC, of Cancer Care Ontario, a mix of provincial and federal taxes support the financing of public healthcare, but responsibility for actually organizing and delivering care is assigned at the provincial level. “The overall principles that govern healthcare are determined by the Canada Health Act (CHA), something that Canadians hold very dear,” Dr Sawka related.

These principles emphasize that Canadian healthcare should be universally accessible, portable, comprehensive, and that the system should be publicly administered, she outlined. Under this system, Canada spends 10% of its gross domestic product on healthcare, compared with 16% in the United States. The public system pays for hospitals, physicians, and many drugs, but is also supplemented by private insurance that can cover items not provided by the public plan, such as certain drugs.

In addition, “Oncologists have nothing to do with buying and selling drugs” in Canada, Dr Sawka pointed out, so “they don’t have a financial stake in terms of the type of drugs they order or how long they give them. That actually helps to get that part of the pressure off their backs.”

Evaluating New Innovation

With new, costly cancer medications entering the market, a look at how other nations evaluate these drugs and make coverage decisions offered contrasts to the US system. In France, Ms Pickaert noted, access to the new medicines is fairly good; for those in clinical trials, early-access programs ensure the patient continued access to the drug they are receiving. The other 4 countries (Italy, Spain, Germany, and the UK) have “compassionate use” programs, as well as temporary protocols that allow drug use for unapproved indications.

But this access does come at a cost, and as Ms Pickaert related, and with their budgetary impact, the French government is trying to restrict these programs. “French oncologists don’t know how much their drugs cost. They’ve got no clue,” said Ms Pickaert.

Increasingly in Eastern and Western Europe and Japan, said Dr Dalrymple, a risk-sharing approach to new oncology drugs is being used. With this approach, drugs are given for a certain number of cycles or for a limited period of time, and then an evaluation of efficacy is made. If the drug is considered efficacious, treatment continues and reimbursement is made by the central authority to the manufacturer, with no financial liability assigned to the patient. Two situations may financially burden the patient, however. One is conditional access, wherein a patient who has previously failed a treatment is given access to a new agent, or where a drug has been approved but is not yet available in the centralized healthcare system.

In Canada, drug manufacturers first must get a certificate of compliance from the federal government indicating that its drug is safe and effective, and pricing is controlled. But whether a drug is included on a publicly funded formulary is a provincial decision guided by a panel of cancer clinicians who evaluate new drugs. “Cost-effectiveness is a part of every deliberation,” Dr Sawka pointed out, “and it’s always ‘how cost-effective is this drug in relation to a more standard approach?’” For manufacturers, the evidentiary bar can shift, since “every province has its own way of doing [these evaluations].” So, for example, in Ontario, Avastin (Bevacizumab) for colon cancer is covered for everybody, while Avastin for breast cancer wasn’t even forwarded to the formulary, as the evidence was not seen as compelling enough, she said.

For the evaluating panel, there are clear nos and yeses, but “many, many drugs are in the middle,” said Dr Sawka. “Because most oncologists in Canada feel that...they are stewards of a set of resources, they have a long history of healthy skepticism about the value of new drugs. Yes, they’d like to use them if they’re effective, but they want to make sure they’re adding value.”

Values Influence Value Decisions

Dr Sawka suggested that the Canadian mindset reflected a pragmatic attitude toward healthcare—on the physician side, a cultural adherence to evidence-based guidelines and population-based medicine; on the patient side, a recognition that “the public purse can’t pay for every single drug, unless it provides significant value.” This recognition of limits continues with fixed amounts allotted to hospitals to cover cancer patient care and to radiation centers for each new case.

In other parts of the world, Dr Dalrymple echoed, centralized healthcare with fixed budgets are the norm, so it is common to have a fixed number of oncologists, a limited number of care settings, and limited amounts of medical equipment. Countries have instituted top-down efforts to try and contain costs by moving treatment to the outpatient setting, but in some countries, notably the Middle East and Eastern Europe, there is also a patient mindset that emphasizes restraint when accessing healthcare. As Dr Dalrymple put it, these patients think, “Don’t bother the doctor unless it’s really, really bad.”

In the UK, government-imposed restrictions on financing for cancer care led to involvement by that country’s supreme court. Patients were electing to pay privately for treatment for their cancer, Dr Dalrymple explained, and the government interpreted this as the patients exempting themselves from the National Health Service as far as their cancer treatment was concerned, an interpretation that was later overturned by the courts. He also cited a study that found that because of the refusal of the National Institute for Health and Clinical Excellence (NICE) to approve a number of drugs for a range of rare cancers, 20000 deaths had occurred in the UK in the last 3 years.

Unlike these countries, France and Germany do not seem to recognize that there are limits to healthcare resources, said Ms Pickaert, and people from other countries, especially the UK, travel to here to access care more quickly, albeit paying the cost out of pocket.

Beyond these big-picture issues of access and affordability, efforts to study utilization, outcomes, and cost in a way that will positively impact patient care are now being undertaken. Dr Sawka profiled a study in Ontario that assessed emergency department use by cancer patients in the last 4 weeks of life and chemotherapy in the last 2 weeks of life. This sort of review is intended to “drive the discussion—what should happen, what constitutes good practice?” she commented.

In closing, the panel considered what lessons each country’s healthcare system might offer to the others. America, Dr Sawka indicated, provides a lesson in entrepreneurial spirit. “What we could use in Canada is the competitive driver for innovation. Having a single-payer system is a blessing and a curse.” Innovations such as pay for performance and electronic records systems have originated in the United States and come to Canada. “The creativity that you see in the US healthcare system comes from competition,” she said.

Both Dr Dalrymple and Ms Pickaert emphasized their countries’ treasuring of universal access for all. Ultimately, the whole debate revolves around what kind of social contract the people want, said Ms Pickaert. In Europe, there is acceptance of the notion that “I will pay for others, and when I get sick, they will pay for me.” The organizing principles of American healthcare, she indicated, are difficult for Europeans to understand.

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