April 18, 2014

Cost of treatment could influence doctors’ advice

The shift from treatment effectiveness to cost suggests that doctors are starting to redefine their roles from being concerned exclusively about individual patients to exerting influence on how health care money is spent. But some see patient trust at risk if savings becomes a goal.

Saying they can no longer ignore the rising price of health care, some of the most influential medical groups in the nation are recommending that doctors weigh the costs, not just the effectiveness, of treatments as they make decisions about patient care.

The shift, little noticed outside the medical establishment but already controversial inside it, suggests that doctors are starting to redefine their roles from being concerned exclusively about individual patients to exerting influence on how health care money is spent.

“We understand that we doctors should be and are stewards of the larger society as well as of the patient in our examination room,” said Lowell E. Schnipper, a medical doctor who is chairman of a task force on the value of cancer care at the American Society of Clinical Oncology.

In practical terms, guidelines being developed by the medical groups could result in doctors choosing one drug over another for cost reasons or even deciding that a particular treatment — at the end of life, for example — is too expensive. Some critics have said that making treatment decisions based on cost is a form of rationing.

Traditionally, guidelines have heavily influenced the practice of medicine, and the latest ones are expected to make doctors more conscious of the economic consequences of their decisions — even though there is no obligation to follow them. Medical society guidelines are also used by insurance companies to help determine reimbursement policies.

The society of oncologists, alarmed by the escalating prices of cancer medicines, is developing a scorecard to evaluate drugs based on their cost and value, as well as their efficacy and side effects. It is expected to be ready by this fall.

And the American College of Cardiology and the American Heart Association recently announced that they would begin to use cost data to rate the value of treatments in their joint clinical practice guidelines and performance standards.

Some doctors see a potential conflict in trying to be both providers of patient care and financial overseers.

“There should be forces in society who should be concerned about the budget, about how many MRIs we do, but they shouldn’t be functioning simultaneously as doctors,” said Martin A. Samuels, a medical doctor who is chairman of the neurology department at Brigham and Women’s Hospital in Boston.

He said doctors risked losing the trust of patients if they told patients, “I’m not going to do what I think is best for you because I think it’s bad for the health care budget in Massachusetts.”

Still, some analysts say that there is a role for doctors to play in cost analysis because not many others are doing so.

“In some ways, it represents a failure of wider society to take up the issue,” said Daniel P. Sulmasy, a medical doctor and professor of medicine and ethics at the University of Chicago.

Generally, Medicare is not supposed to consider cost effectiveness in coverage decisions, and other government attempts to do so are susceptible to criticism as rationing. Insurers also perform cost analyses.

The cancer and oncology societies are not the only ones considering costs. A review last year of clinical guidelines issued by 30 of the largest physician specialty societies found that 17 of them explicitly integrated costs. That appeared to be an increase from 2002, when a different review had found more limited use of economic analysis.

Also, in recent years, as part of a campaign called Choosing Wisely, many medical societies have submitted lists of the top five procedures, tests or products to be questioned because they are considered wasteful.

More than 100 cancer specialists last year publicly criticized the price of drugs to treat leukemia. Doctors at Memorial Sloan-Kettering Cancer Center publicized their refusal to use a colorectal cancer drug they deemed too expensive.

The cardiology societies say the idea that doctors should ignore costs is unrealistic because they already have to consider the financial burden placed on the patient, if not society.

“Protecting patients from financial ruin is fundamental to the precept of ‘do no harm,’ ” the societies wrote in their paper outlining the new policy.

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