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economics of cancer care TABLE 11.5. Barriers to use of cost and cost-effectiveness data.

Group

Barrier

Patients

Physicians

Payers/government

— Patients are more willing to receive toxic treatments for small benefits than well people

— Patients may feel entitled to treatment regardless of cost

— Cost may not become an issue for patients until out-of-pocket expenses are prohibitive

— Strict effectiveness data may not reflect improved quality of life seen with palliative treatments

—Physicians may be trapped between patient demands for all possible treatment and societal demand to limit care

—For most physicians, there are no rewards to limiting care

—For many oncologists, the supportive care drugs with high incremental cost-effectiveness ratios may be the most lucrative to the practice

— Payers may not want to antagonize their secondary constituents, consumers, by not covering some desired services based on cost-effectiveness data

—The lawsuits about high-dose chemotherapy with stem cell transplant for metastatic breast cancer make some payers leery of confrontation incentive to limit a patient's access to care; in fact, for many oncologists the supportive care drugs such as erythropoietin, filgrastim, and bisphosphonates help support their practice. Physicians may also be hesitant to set limits on cancer care of their own accord outside of widely accepted professional standards; this is both uncomfortable for the physician and probably inappropriate bedside medical rationing that may not be based on sound evidence. For example, a physician may decide that palliative radiation therapy for painful bone metastases should be replaced by opioid medication alone because costs of radiotherapy are assumed to be very high. In fact, studies tell us that radiotherapy in such settings is indeed cost-effective and falls well within accepted ratio standards.20 In the interest of balancing the appropriate delivery of care with responsible financial prudence, clinical guidelines addressing these issues should continue to be examined by appropriate consensus

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