Issue No. 6: Americans Have Greater Access to New Medicines for Cancer

Is It a Coincidence That Survival Rates Are Higher Here, Too?

In recent years, cancer drugs have been dominating news both because of the benefit they bring and the price tags. If you live in the United States, getting access to those drugs is a good deal easier than in other developed countries. That is the conclusion of a studyjust published in the February issue of the Journal of Managed Care and Specialty Pharmacy. 

They looked at the 41 anti-cancer drugs, covering 45 indications (an indication is evidence to initiate treatment of a disease), approved in the U.S. between Jan. 1, 2009, and Dec. 31, 2013. They examined how many of those indications had been approved by regulatory agencies equivalent to the U.S. Food & Drug Administration in the U.K., France, Australia, and Canada. They also examined how many of these drugs were covered by the Medicare program in the U.S. and by government health insurance in the other countries.

Here is what they found:

• Of the 45 drug indications approved in the U.S., just 29 (or 64%) were approved by the European Medicines Agency (EMA). The U.K. itself approved all of those, but France approved only 28. Canada’s drug regulator approved 34 of the 45 indications; Australia, 32.
• In the U.S., Medicare covered all 45 of the indications. But health insurance systems in the four other countries covered fewer than half. The U.K. covered 21; France, 19; Canada, 15; and Australia, 14. The authors write: “Australia, Canada, and the United Kingdom used cost-effectiveness analyses explicitly in their coverage decisions. France considered cost implicitly.”

All five countries, for example, approved Stivarga (Regorafenib) for metastatic colorectal cancer, but the indication was covered by insurance only in the U.S (through Medicare) and the United Kingdom. Zytiga (Abiraterone) was approved to fight prostate cancer in all the countries but not covered in Canada.

What is the effect of limiting access to effective and safe cancer drugs? The answer is beyond the scope of the study, but earlier research gives some clues. For instance, in November 2014, a large international study of cancer survival rates called CONCORD 2 was published in The Lancet. The survival results for five common cancers in seven countries, as related by the U.S. Centers for Disease Control, found the U.S. performing best by far.

The study looked at proportion of patients with different kinds of cancers surviving at least five years. The United States was number-one out of the seven countries for three of the five cancers (breast, colon, and prostate), second in lung cancer, and sixth in childhood leukemia. No other country came close to that record. 

The U.K., for example, ranked last among the seven countries in every category but one. Japan led for lung cancer but finished sixth for breast and prostate and last for childhood leukemia.

Here is a table with some of the results….
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It is sensible to conclude that at least one reason for these higher survival rates is greater access to the best anti-cancer pharmaceutical treatments. A broader conclusion is that smart spending on health care can produce better results.  

Elevating Primary Care

But then again, we have a lot to learn from European health systems. The surgeon Atul Gawande is also one of America’s best writers of non-fiction. His recent piece in The New Yorker, “The Heroism of Incremental Care,” celebrates the role that primary physicians and nurse practitioners can play in keeping people healthy and holding down costs. As the subhead puts it: “We devote vast resources to intensive, one-off procedures, while starving the kind of steady, intimate care that often helps people more.”

Gawande gives vivid examples of how primary-care doctors, working closely with patients, can diagnose and treat difficult diseases that are immune to heroic intervention. He thinks primary care is the future: “The more capacity we develop to monitor the body and the brain for signs of future breakdown and to correct course along the way – to deliver ‘precision medicine,’ as the lingo goes – the greater the difference health care can make in people’s lives, as well in reducing future costs.”

Costs are what this newsletter is all about. Gawande cites a compensation survey that shows that the five highest-paid specialties in medicine – orthopedics, cardiology, dermatology, gastroenterology, and radiology – “have an average income of four hundred thousand dollars a year.” He writes, “All are interventionists: they make most of their income on defined minutes- to hours-long procedures…and then move on. (One clear indicator: the starting income for cardiologists who perform invasive procedures is twice that of cardiologists who mainly provide preventive, longitudinal care.)”

The lowest-paid specialties are pediatrics, rheumatology, family medicine, internal medicine, and the like – at about half that of the highest. “All are incrementalists – they produce value by improving people’s lives over extended periods of time, typically months to years.”

If we devoted more resources to these incrementalists, then it’s likely that the high costs of intervention could be lowered. Gawande uses hypertension as an example. Some 30% of Americans have high blood pressure, but “only half are adequately treated.” The resultcan be stroke, heart attack, or kidney disease.

Gawande spoke to Asaf Bitton, a highly regarded internist who said that primary care “is the medical profession that has the greatest over-all impact, including lower mortality and better health, not to mention lower medical costs.” Europe seems to understand this much better than we do. Bitton referred to a study in Spain that focused on strengthening primary care in various regions and found that mortality rates fell there. Also, “Medicare plans that increased co-payments for primary-care visits – and thereby reduced such visits – saw increased hospitalization rates.”

Some primary care – diagnosis and intervention – needs physicians. But management of the disease, which in many cases is just as important, can be performed by medical assistants with less training. And often done a lot better. Follow-up to be sure the patient is compliant, which can simply mean a phone call or an email, is a low-cost way to prevent a stroke, which leads to an expensive hospital stay and rehabilitation.

The Cost Burden of Smoking

In addition to new drug discoveries, perhaps the best news in health care in recent years has been the decline in smoking. But a study in the new issue of the journal Tobacco Control finds that health-care costs due to tobacco – and economic losses due to smoking’s effects (for example, productivity at work) – are still very high. Globally, tobacco is the cause of 5.7% of health expenditures and its total costs represent 1.8% of the world’s GDP.

The U.S. figures aren’t easy to find in the study, but the table is here. The researchers calculate that U.S. health costs due to smoking were $203 billion in 2012 (that’s about two-thirds of the cost of all the pharmaceuticals used in this country), or 7.4% of all health costs. Total costs represent 3.2% of GDP. An estimated 15% of Americans smoke, compared with 42% a half-century ago. But there are enough smokers to have a huge impact on health-care costs.

The study -- by Mark Goodchild, Nigar Nargis, and Edouard Tursan d’Espaignet – is further evidence that, if we truly want to bend the cost curve, we need to focus on changing behaviors.

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