Rationing healthcare: who's responsible?

Let’s start with the easier vignette: Vignette 3 illustrates the failure of the physician to discuss transition to hospice care. As the authors describe, a dying man with pancreatic cancer “had an ECOG performance status of 3 at his last visit...you were to see him again in clinic next week to discuss hospice....” Not making time for this important communication at his last visit was a tremendous wasted opportunity, and it opened a time window for an adverse event. Why not discuss the use of hospice during the patient’s first visit and, following a best-practice approach, have a formal hospice information visit to establish this best practice and the finality of this patient’s illness when he still has 3 to 6 months left to live, as recommended by the American Society of Clinical Oncology?[1] Why bring the patient back to discuss hospice later? The authors discuss “anticipating...patient decline.” Cancer is not sudden death, and the point at which a person has less than 6 months to live is actually very predictable.[2] We have to stop making excuses; we need to have these discussions with patients at several points along the end-of-life continuum.[3,4] Patients who have these services in place when they leave the hospital have a 4% chance of readmission, vs a 25% chance of readmission if they don’t.[5] Now for the harder part: costs and discussion of costs. These issues have been debated for decades, with no resolution.[6,7] For example, let us consider and contrast two health systems, US Oncology and Johns Hopkins Medicine. US Oncology recently started giving their patients, at every visit, a summary statement of the total cost of their care and the patient’s responsibility. At our institution, patients are only aware of their own cost responsibility, which is determined during pre-authorization. The patient may never see the total cost, and absolute financial responsibility is only determined when bills come months later. We do not know which is a better approach, but there are financial managers in the office who know the costs and can discuss them with the patient. We cannot plead ignorance forever. In their article, Drs. Tenner and Helft have countered that while some believe rationing can only be accomplished at the level of the individual provider, many oncologists feel ethically conflicted by the idea of balancing societal needs to ration care against their professional responsibility to advocate for their patients. The authors suggest that oncologists “provide information about the relative risks (including the financial risks) and potential benefits.” This represents a substantial change in practice, as many oncologists feel unprepared to give such information, and most of us have little training or even a framework for such a discussion.[8,9] We were unable to find a single published work describing the impact of real costs on patients and the effect of care costs on the physician-patient relationship. We have just started a clinical trial to explore this question—the first of its type ever. Acting in the best interest of our patients must encompass the whole person and prepare patients for the effects that their disease may have on their life beyond their health. This includes the financial impact of their treatment decisions and ensuring that there are no feelings of guilt for financially burdening their families. We believe this is as much an ethical imperative as providing the most life-prolonging therapy. We should continue to bend the cost curve in cancer care by removing the financial incentives to use the most expensive chemotherapy.[10-13] Conflicts of interest and ethical challenges arise when we make money from buying and selling chemotherapy. If practices choose the chemotherapy that makes the most money rather than the least expensive one with equal efficacy, we have used both societal and patient-family resources inappropriately.[10]