SIDEBAR: Expect Questions and Respond with Reasoned Explanations

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“Soaring spending has presented the medical community with a new obligation. When choosing treatments for a patient, we have to consider the financial strains they may cause alongside the benefits they might deliver,” three physicians from Memorial Sloan-Kettering Cancer Center (MSKCC) in New York asserted in an op-ed piece in The New York Times.1 Noting that 1 in 10 patients with cancer now reports spending more than $18,000 out of pocket for care, the MSKCC physicians also cited a study finding that 2% of patients with cancer were driven into bankruptcy by the disease and its treatment.

When patients bring up the costs of medications and say they are not filling prescriptions because they can’t afford it, these are usually the ancillary medications, such as low-molecular-weight heparin or advanced antinausea regimens, where the copays can be hefty, according to Leonard B. Saltz, MD, one of the article’s authors. “If the copays are for chemotherapy agents, then patients will be quite vocal with their doctors about whether they can afford to keep doing this or not.”

Honest and Open Discussion

When that happens, “physicians can discuss honestly and openly with patients what the incremental benefits are of one approach vs another and try to work with them to better understand their options. Is this, in fact, a bill they’re unable to pay—in which case, what are the alternatives—or is this a bill they would rather not pay, but if looked at more closely, might be worth it to them?” Dr. Saltz asked.

“There are so many different scenarios,” he continued. “You could have a person who truly doesn’t have the means, or you could have a person who is quite well off but is just indignant about having to pay for some aspect of health care because, as Americans, we tend to think that whatever third party is paying ought to pay for everything.”

In the case where two agents offer similar benefits but differ in cost and toxicity, patients need to know the facts to make decisions for themselves. “To say to a patient, ‘I am going to save money by giving you a more toxic agent,’ is not something that most people would care to accept,” Dr. Saltz said. But if the patient was spending a lot of money on treatment and the less expensive agent offered “substantial savings and an acceptable toxicity,” then “you might have that kind of conversation,” Dr. Saltz said. In current practice, he added, that conversation is not very likely to occur. ■

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