A Framework For Patient Harm

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  • 09/01/2015
My article from the Louisville Courier-Journal on the ASCO Value Framework.  It can also be read as an analysis of Dr. Daniel Goldstein's effort to measure the value of a new medicine for people with stage IV squamous, non small cell lung cancer...

A group of cancer doctors has apparently decided to rewrite the Hippocratic Oath.

The ancient pledge charges physicians with applying “all measures that are required” for the benefit of the sick. The docs heading up the American Society of Clinical Oncology want to add a caveat — “unless those measures are too expensive. Then just let the patient die.”

The oncologists’ group has developed a “conceptual framework” that relies on cost-benefit analysis to determine the most “valuable” treatments for different patients.

Sounds innocent enough. But healthcare outcomes cannot be reduced to cost-benefit calculations. By focusing on the cost of a treatment — rather than the benefit it could deliver — the oncologists are allowing dollar signs to dictate whether a patient lives or dies.

Under ASCO’s framework, new treatments will be judged “based on clinical benefit, side effects and cost.” Those are the exact same measures health insurance companies use in limiting patient access to treatments. Indeed ASCO wants insurers to use its calculator to “evaluate the relative value of new treatments” as they develop “benefit structures, adjustment of insurance premiums, and implementation of clinical pathways and administrative controls.”

Such “controls” could include shifting drugs to the highest cost-sharing tier of an insurance plan or requiring patients to try older, cheaper drugs before gaining access to the most cutting-edge therapies.

Never mind that the Obama Administration has warned “placing most or all drugs that treat a specific condition on the highest cost tiers discourages enrollment by individuals based on age or based on health conditions” is discriminatory.

The oncologists are effectively asking insurers to discriminate against cancer patients — in direct contradiction of the Affordable Care Act’s intent.

ASCO’s framework openly ignores what really matters — benefit to patients.

Consider how the framework attempts to dictate how long a person “should” live. It claims that patients “overestimate the benefits of treatments that sometimes extend life by only weeks or months.”

In other words, ASCO has concluded that a treatment that can keep patients alive for weeks or months has no real value.

The framework assigns zero value to any treatment that doesn’t increase survival by 20 percent. Right off the bat, numerous treatments for pancreatic, brain, lung, and stomach cancer today would be deemed worthless by the formula.

That 20 percent figure is completely arbitrary. Consider the case of someone with lung cancer who is alive today because of the accumulation of treatments that never made that arbitrary threshold. Cardiologists hailed a just approved drug that reduces the risk of death from heart failure by 20 percent as revolutionary.

Under ASCO’s framework, sorry — not good enough.

Between 1987 and 2000, various AIDS therapies increased patient life expectancy by less than 20 percent a year. Had ASCO’s framework been in force then, thousands of AIDS patients who benefited from those treatments would not be alive today.

ASCO defends its guidelines by claiming that expensive new treatments have sown “unrealistic patient and family expectations that lead clinicians to offer or recommend some of these services, despite the lack of supporting evidence of utility or benefit.” The American healthcare system can’t afford limitless spending on cancer treatments, the group says.

It’s true that spending on cancer drugs has risen. In 2014, it topped $100 billion. But that figure represents just 1 percent of U.S. healthcare spending.

What’s more, these medicines work — and are worth their price tags.

Successful drug therapies reduce overall medical costs by diminishing the need for future doctor visits and hospital stays. According to a study from the Center for Value and Risk in Health, specialty drugs often cost more than traditional drugs but “also tend to confer greater benefits and hence may still offer reasonable value for money.”

Successful treatment does more than just lower health costs and offer patients priceless extra time with loved ones. It also benefits the nation. According to one study, cancer survivors have contributed $4.7 trillion to the economy since 1990, simply by living and working longer.

Indeed, according to a Health Affairs study, “current technology assessments, which often determine access” to cancer therapies “may be missing an important source of value to patients and should either incorporate hope into the value of therapies.”

By valuing treatments based on what they cost insurance companies rather than the benefit they provide to patients and their families, the ASCO framework violates both the letter and spirit of the Hippocratic Oath. It should be scrapped before it puts patients in danger.


Center for Medicine in the Public Interest is a nonprofit, non-partisan organization promoting innovative solutions that advance medical progress, reduce health disparities, extend life and make health care more affordable, preventive and patient-centered. CMPI also provides the public, policymakers and the media a reliable source of independent scientific analysis on issues ranging from personalized medicine, food and drug safety, health care reform and comparative effectiveness.

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