Delivering Affordable Cancer Care death of a dream?

Transcription

1 Delivering Affordable Cancer Care death of a dream? Richard Sullivan MD PhD Prof, Cancer Policy & Global Health academia.edu/richardsullivan

2 Affordability & sustainability are complex & multifaceted public policy issues

3 Cancer care exposes the weaknesses and strengths of healthcare systems rapid growth in health expenditures creates an unsustainable burden with far-reaching consequences cancer is such a prevalent set of conditions and so costly, it magnifies what we know to be true about the totality of the health care system. It exposes all of its strengths and weaknesses Delivering affordable cancer care in the 21 st century. National Cancer Policy Forum & Institute of Medicine

4 . worth remembering that not everyone believes we have a problem with affordability. The Cost Disease: why computors get cheaper and healthcare doesn t. William Baumol,

5 Economics of cancer care & research cannot be divorced from public policy of healthcare costs per se

6 Talking about cost of cancer makes people rather angry. Socio-Demographic Challenge 1. Sullivan R, Purushotham A. An analysis of the media reporting of the Lancet Oncology Commission Lancet Onc (13): 12-13

7 Lets start with a postmortem of the reasons why we have a problem The Public Policy Challenge

8 We still don t have a good picture of the current economic burden

9 Sustainability is not just about absolute costs. understanding and modelling the impact of drivers is critical

10 What keeps policy-makers awake at night. Titanic moment.at current trends cancer will come to a fiscal cliff..

11 Most patients will live and die in places far removed from the countries that led on delivering modern cancer systems of care and research Source: United Nations, World Population Prospects: The 2008 Revision (medium scenario), 2009.

12 Affordable cancer care systems in high-income countries have little relevance for emerging economies with their double, triple quadruple burden Charles Hughes & John Hunter. Disease and Development in Africa, Soc Sc & Med 3:

13 But all countries are facing three major demo-economic problems: 1. AGEING

14 the world in 2009.

15 2. COLLAPSING DEPENDENCY RATIO Source: Population Division of the Department of Economic and Social Affairs of the United Nations Secretariat, World Population Prospects: The 2006 Revision and World Urbanization Prospects

16 3. NO MORBIDITY COMRESSION 1 Fries, JF. (1989) Compression of morbidity. Near or far? Milbank Quarterly, 66(2):

17 Everyone feeling cheerful still?

18 Lets also look at the techno-social pressures on delivering affordable and sustainable systems

19 We have a strong cultural tropism for proto-health behaviors, and much of our decision-making is framed by evolution: we are after still primates! We know from prospect theory that patients are risk seeking and put far greater emphasis on hope thus over valuing innovation Sullivan R, Behncke I, Purushotham A, Why do we love medicines so much? An evolutionary perspective on the human love of pills, potions and placebo. EMBO Reports 2010, 11(8): 1-7.

20 Price and volume are creating serious issues for the costs of new cancer technologies, particularly medicines (Global sales ($M) )

21 Real question mark about how much healthcare systems can really afford more for less.. Molecular targeted Classical chemotherapy

22 Rapid trajectory of costs: until FU/LV was standard for colorectal cancer $96 USD per month to $40/53,000 USD pm = c. 520% increase

23 BUT we need to ensure that creativity isn t sacrificed in our efforts to deliver affordable cancer care systems.. Value of new technologies in cancer is based on perception of them as having the power to heal (1). New medicines may facilitate further fundamental research and/or drive further development. Important for the general zeitgeist of development in this area (2). (1) Sjaak van der Geest et al. The charms of medicine. Med. Anthropol. Quart. 1989, 3(4): (2) Peter Drahos. Trading in public hope. Annals, AAPSS. 2004, 592: 18-38

24 Beyond the economics of technologies, care, etc there are major principles of public policy at stake in the affordability debate

25 Poverty & inequality & affordable cancer care Institute of Development Studies

26 Poverty and inequity are real issues for high income countries as well Failures in politics and economics are related, and they reinforce each other. Market forces in cancer have shaped it in ways that advantage the top at the expense of the rest. A system where political and market forces are sensitive to commercial interests drives inequality.

27 Europe needs to be beware.. Median income stagnating & falling Growing inequality in educational attainment 15% in poverty and rising & 1.5M living on less than 2USD per day If you are from an ethnic minority then you will have lost 53% of your wealth since Institute of Medicine. Delivering affordable cancer care in 21 st century 2013.

28 Is the cost of cancer killing the patient? Pharmacogenetics is dead and warfarin killed it

29 Worldwide the answer is probably yes Globalisation of cancer risk factors is a major hurdle to sustainable and affordable care Cost effective surgery & radiotherapy are the key In global cancer policy terms high income personalised cancer medicine has little irrelevance Need to re-create and rediscover new affordable systems (1) David Doller. Is globalisation good for your health? Bull WHO 2001, 79: (2) David Woodward et al. Globalization and health. Bull WHO 2001, 79:

30 Cancer is not a market or an ideological battleground but it is being treated like one

31 So what to do? Just need to accurately measure costs & link to outcomes, Robert Kaplan & Michael Porter, Sept, 2011 Harvard Business Review Stop regulatory divergence between marketing authorisation & HTA processes. Reduce / stop off label use Mandatory integration of socioeconomic studies into clinical research Integrate insights from behavioural economics Mandatory context specific HTA processes for all interventions

32 We talk a lot about equality yet we are far from this need to find ways to drive the social contract for cancer Fabienne Peter. Health equity & social justice. J Applied Philosophy, (2):

33 If we aren t more intelligent about addressing the affordability of cancer it will end up looking like this. A supermodel with a Louis Vuitton handbag.lovely to look at, very expensive, affordable to only few and of no real value to society as a whole