Pharmacy & Therapeutics - January 2009 - (Page 25) OPINION: Economic Instability and Health Care Costs Quality of life has always been an important issue in health care, but it has now been thrust to the forefront because of the economic recession. Is a newer, targeted biologic therapy that costs thousands of dollars per month truly worth the extra expense and the potential for adverse effects, when it provides a modest extension of overall survival of only a few extra weeks or months? In the past, many patients have looked at this extension as a chance to live another year or more. In just the past few months, however, many cancer patients and their families have begun to rethink these attitudes. They are considering the financial costs that are associated with this additional time and other implications as well. What quality, what value of life will they experience? Is living longer worth declaring bankruptcy? Or is it more valuable to preserve one’s financial assets so that they can be passed onto posterity? Such matters also have ramifications for health care providers and P&T committees. Patients have undergone a shift in priorities, precipitated in part by the current economic conditions; this, in turn, has prompted the need for health care administrators to come up with new ways of thinking about cancer treatment and health care more broadly. Should end-of-life measures be pursued in lieu of additional treatment? Are palliative care and supportive management of associated symptoms more viable alternatives to treating the underlying disease with active and aggressive courses of therapy? Hospice is an end-of-life program that provides assistance to terminally ill patients who have abandoned treatment options and have chosen instead to focus on comfort during their last months of life. Hospice admissions have been steadily increasing over the past five years; an estimated 1.4 million patients received its services in 2007.10 Hospice care is covered under Medicare, Medicaid, and most private insurance, and patients receive care whether or not they can pay. A 2007 study demonstrated the cost savings of hospice care for both beneficiaries and Medicare to be an average of $2,309 per patient; for cancer patients, hospice use decreased Medicare costs for up to 233 days of care.11 Hospice and other forms of palliative care are increasingly being viewed as preferable to more costly, end-of-life treatment efforts—especially for the elderly, who may be fighting for only a few more months of life at an exorbitant cost. With the economy apparently acting as a catalyst in the shift in societal opinions about death and the value of life, hospice care and other end-of-life measures seem likely to continue to increase steadily or perhaps even to spike sharply in the future. The traditional patterns of medication use are also likely to change, with therapeutic doses being adjusted to provide a palliative rather than a curative effect. When one is deciding about which medications to use, overall survival will no longer be the primary focus; instead, the focus will be on quality of survival, an increasingly important marker of effectiveness, even though it is subject to a variety of interpretations. Drug therapy aimed at managing symptoms, such as pain and depression, is another alternative to consider in place of the traditional drug regimen intended to combat a specific disease. Less intensive therapies can provide an acceptable quality of life without exorbitant costs or untoward side effects, commonly experienced with the aggressive use of biologics and other chemotherapeutic agents. Stakeholders in health care should consider these options, possibly at a much earlier point in the disease course than they used to—particularly with patients for whom comfort and quality are equally if not more important than overall survival. CONCLUSION The current economic crisis has called into question our society’s historical tendency to delay death whenever possible and at all costs. Now more than ever, value and quality of life are gaining in importance, a trend that will force stakeholders to determine the value proposition of therapies in a different way. That is, they will need to consider not only whether a therapy is safe and effective but also the true value it might bring to patients in terms of health benefits and quality of life in relation to its cost. This is a timely topic that everyone involved in health care will be forced to address, in response to patients’ demands and needs. This shift in attitudes will undoubtedly continue to disrupt and thereby influence our models of health care utilization and the pharmacoeconomics of new medications. REFERENCES 1. Report: Economy is sickening U.S. hospitals, November 19, 2008. Associated Press. Available at: www.msnbc.msn.com/id/ 27809791. Accessed November 15, 2008. 2. Survey: Eight in 10 Americans say economy will affect ability to pay for healthcare. Jacksonville Business Journal, November 3, 2008. Available at: www.bizjournals.co/jacksonville/stories/ 2008/11/03/daily9.html. Accessed November 14, 2008. 3. American Cancer Society. Treatment topics and resources: Costs of cancer. Available at: www.cancer.org/docroot/MIT/ content/MIT_3_2X_Costs_of_Cancer.asp. Accessed November 16, 2008. 4. Castle L, Russek S. Fighting cancer, soaring costs. Business Insurance, November 3, 2008. Available at: www.businessinsurance. com/cgi-bin/article.pl?id=26365. Accessed November 13, 2008. 5. Saul S. In sour economy, some scale back on medications. The New York Times, October 22, 2008. Available at: www.nytimes. com/2008/10/22/business/22drug.html?_r=1&pagewanted= print. Accessed November 20, 2008. 6. Thomson Reuters survey finds cancer patients forgoing treatment because of cost. Yahoo! Finance, October 13, 2008. Available at: http://biz.yahoo.com/prnews/081013/clm070.html?.v=101. Accessed November 14, 2008. 7. Szabo L. Study: Many cancer patients forgoing care because of cost. USA Today, October 12, 2008. Available at: www.usatoday. com/news/health/2008-10-12-cancer-costs_N.htm?csp=34. Accessed November 14, 2008. 8. Nelson R. Oncologists under increasing pressure to address economic issues in cancer care. Medscape Medical News, July 14, 2008. Available at: www.medscape.com/viewarticle/577452. Accessed November 12, 2008. 9. Fuhrmans V. Consumers cut health spending, as economic downturn takes toll. The Wall Street Journal, September 22, 2008. Available at: http://online.wsj.com. Accessed November 13, 2008. 10. National Hospice and Palliative Care Organization. NHPCO Facts and Figures: Hospice Care in America. Alexandria, VA: October 2008. Available at: www.nhpco.org/files/public/Statistics_ Research/NHPCO_facts-and-figures_2008.pdf. Accessed November 20, 2008. 11. National Hospice and Palliative Care Organization. Hospice care saves money for Medicare, new study shows. November 8, 2007. Available at: www.nhpco.org/i4a/pages/Index.cfm?pageID=5386. Accessed November 20, 2008. 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