ASCO Connection

July 2017

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Doctors do not have the ability to unilaterally lower the prices of drugs. Doctors do have the ability to be aware of the prices of the drugs, tests, treat- ments, and recommendations we offer, both directly in terms of out-of-pocket expenses to our patients and more indirectly to society as a whole. Some have argued that it is only the imme- diate out-of-pocket expense of the individual that should be considered by doctors and that societal costs are not relevant to a patient-physician relation- ship. I respectfully disagree. Societal costs ultimately are distributed across the population, and all insured patients eventually bear these costs in terms of increased insurance premiums. The price of insurance and the percentage of paychecks that go toward health care costs have been increasing at a substantially more rapid rate than the increases in average worker wages or inflation. The term financial toxicity has gained increasing traction in our understanding of what these costs are doing to our patients on a regular basis. Even when the initial out-of- pocket expense may appear small, one can realistically expect that these costs will appear in the insurance premiums for all in the years to come. Even if one were to take the position that the physician focus should be on immediate out-of-pocket expenses of an individual patient (a short-sighted view, as I outlined in the previous para- graph), this would imply a responsibil- ity to understand the coverage and actual out-of-pocket exposure of each patient, as well as, arguably, the abil- ity of each patient to manage those expenses. This often may be beyond provider abilities. It is quite reasonable, however, to assume that vulnerability a patient may have toward the poten- tial cost of even a small part of that therapy increases with more expensive therapy. Physicians see a decrease in simple copayments with fixed nominal costs and an increase in coinsurance charges, whereby the patient will pay a fixed percentage of the price of the drug. In this context, the more expen- sive drugs create greater out-of-pocket expenses at the same time that they contribute to the aggregate cost of health care and the necessarily com- pensatory increases in insurance pre- miums going forward. " I am not making a judgment about whether the price is too high, too low, or just right. I am simply saying that [providers] must stop putting our heads in the sand and pretending that we do not need to know, think about, or talk freely about the price." —Dr. Leonard B. Saltz ASCOconnection.org I 25

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