Both the American Society of Clinical Oncology (ASCO) and the National Academy of Medicine recognize cost-of-care conversations to be an important aspect of the clinician-patient relationship and an essential component of high-quality cancer care.1 Financial toxicity has been shown to play an important role in treatment success. Increased cost of care or unexpected financial difficulties are linked with lower patient adherence, delayed or forgone care, and higher mortality.2-4 In fact, as many as 35% of American adults report not getting medical care because of out-of-pocket costs.5,6
“Discussions between patients and clinicians about the costs of cancer care have the potential to improve care delivery and outcomes for patients by fostering informed decision making,” said Ryan Nipp, MD, MPH, of the Massachusetts General Hospital Cancer Center during the 2018 ASCO Annual Meeting.1 Overall, patients have expressed a desire for more help from healthcare providers in addressing the cost of treatment.7,8 Approximately 62% of cancer patients are in debt due to treatment, 42% deplete their life savings within the first 2 years of cancer treatment, and 3% may even have to file for bankruptcy.9,10 Yet despite the recognized importance by both physicians and patients, such cost-of-care conversations rarely occur.6,11,12
In a study of federally qualified health centers, cost-of-care conversations occurred in only 11.9% of physician-patient encounters.13 There is a surprising discordance between physicians and patients about the occurrence of cost-of-care conversations. A study by Reshma Jagsi, MD, DPhil, and colleagues assessed the perspectives of more than 300 oncologists and 2502 patients with early stage breast cancer. Approximately 50% of the medical oncologists reported that someone in their practice discusses finances with patients. In contrast, 72.8% of worried patients reported that they did not get help from their healthcare providers.7
What’s the Price Tag?
New legislation introduced by the Trump administration may help to initiate more cost-of-care conversations between physicians and patients. The new legislation would require pharmaceutical companies to disclose the cost of prescription drugs that cost more than $35 per month and would require that the price be shown in clear, legible font for a sufficient amount of time on television advertisements.14
“Requiring drug companies to level with patients about their drug prices is about working towards a system where the patient — not the insurer, not the drug company, not the government, but the patient — is in control. We are moving from a system that leaves patients in the dark to one that puts them in the driver’s seat,” said Alex Azar, secretary of Health and Human Services, at a recent press conference.15
A group of pharmaceutical companies including Merck, Eli Lilly, and Amgen recently sued the Trump administration in response to the legislation. They disputed that the new law would violate the companies’ rights under the First Amendment, which provides protections for advertisers. They further reasoned that disclosing the list price of drugs may mislead consumers. “We believe the new requirements may cause patients to decide not to seek treatment because of their perception that they cannot afford their medications, when in fact many patients do not pay anything near list price,” said Merck.16
Indeed, a recent study by Jace B. Garrett, PhD, CMA, and colleagues found that disclosing drug prices may lower consumer interest in high-priced drugs, but that the effect could be counteracted if the advertisement included a statement that consumer out-of-pocket costs might be zero.17 As such, several pharmaceutical companies have set up websites detailing potential out-of-pocket costs and sources of financial assistance.16 In June 2019, a federal court judge ruled in favor of the pharmaceutical companies to block the new regulation.18