8. THE COST OF INACTION (ON CANCER)

Amongst the many lessons learned during the pandemic, perhaps the most significant takeaway is the inextricable link between health and the economy.  The Canadian healthcare system has demonstrated agility and innovativeness in its response to the COVID19 crisis, a departure from the traditional inertia observed in healthcare. The lack of a clear economic argument for a range of healthcare interventions, including those aimed at reducing the burden of cancer in this country, only increases healthcare spending and inefficiency. 

According to a recent report by Canadian Health Policy, patented oncology drugs were only 1.3% of overall national health expenditure in 2021; and declined as a percentage of the economic burden of cancer, from 18.4% in 2012 to 15.9% in 2021. New cancer drugs defined as high cost by the Patented Medicines Pharmaceutical Pricing Review Board (PMPRB) accounted for only about one-tenth of one percent (0.12%) of national health expenditure. On average in Canada only 11% of new cancer drugs approved for marketing from 2016 to 2020 in at least one of three jurisdictions (EU, US, CA) were listed on a public formulary as of December 2021. The corresponding percentage for the European Union was 73% and for the United States 90%. Canada was a low priority for new cancer drug launches; approved fewer new oncology drugs; listed fewer new cancer medicines on public formularies. This has resulted in Canadian oncology patients waiting on average 1,835 days from first new drug application across the EU, US, CA to listing on a public formulary versus 788 days for Europeans, and 486 days for Americans.57 

Advancements in technology and new discoveries in medicine have led to breakthroughs that will shape and improve the future of cancer care. However, in order to fully realize the potential of these technologies, it is essential that they become available to patients. To do so requires us to consider the broader economic and societal impacts of their implementation, reevaluating the way we think about and plan healthcare in this country. This shift in thinking is required to fully embrace this new era of healthcare, looking at the impact beyond health expenditure and considering the direct and indirect costs associated with new technologies.

Traditionally, healthcare has been viewed as a cost centre by policy makers and other stakeholders. The focus has been on how much it costs to provide healthcare, rather than on the benefits that investment in an individual’s healthcare can provide in terms of quality of life and economic growth for both the individual and society as a whole. This limited perspective has led to underinvestment in healthcare and a lack of focus on the long term benefits of healthcare technologies and interventions. 

By reframing the discussion to focus on an investment strategy rather than a pricing strategy, we can begin to view healthcare as a building block of an overall economic investment strategy aimed at ensuring citizens have access to proven technologies. This changing paradigm requires combining the therapeutic value of technology and interventions with their economic and social value, looking at the impact beyond health expenditure, taking into consideration the direct costs of their implementation, but also the indirect costs and benefits that result. For example, a new cancer drug may have a high initial cost, but the long term benefits in terms of improved quality of life (QoL) and increased economic productivity may far outweigh that initial cost. 

Considering these broader impacts, we can move beyond the traditional view of healthcare as a cost center and instead see it as a driver of economic growth and social progress. By doing so, we can move towards a more holistic approach to healthcare that recognizes the interdependence of different sectors of the economy and the importance of healthcare as a driver of overall economic growth and social progress. Within these new parameters, the commonly used economic prioritization tools (cost effectiveness analysis, cost benefit analysis, etc.) can no longer be expected to lead to appropriate priority setting for cancer control. Reframing how we define investment and cost, by applying Marshallian efficiency to healthcare, allows payors to spend a little more, if the final results represent incredible advantages, in terms of QoL, GDP, workforce participation (especially for women) economically and socially. This would allow health technology assessments to think about how much it would cost to not reimburse an intervention instead of how much an intervention costs, and healthcare decision makers to think in terms of efficiency vs inefficiency and prioritization in healthcare, and more specifically in cancer care.

Despite clear evidence of a historically large and growing cancer burden, cancer services have generally not been prioritized. The consequences of inadequate investment and delayed interventions in cancer care are profound, both for individual patients and for society as a whole. What more is needed to make the case for investing in cancer control, including the necessity of reducing cancer deaths, the leading cause of death in Canada, but an understanding that the cost of doing nothing has far greater consequences than the cost of any technological or clinical intervention. Decisions are being made behind closed doors without consideration of the human cost  

The costs of cancer care are not only challenges for governments but are increasingly placing a financial burden on patients. From a societal perspective, cancer related costs were CAD 26.2 billion in Canada in 2021, with 30% of costs borne by patients and their families.58 When considering healthcare costs, traditionally the area of greatest focus has been the perspective of the institutional payer such as governments or insurance companies, this approach only covers one component of the total economic burden of cancer. How the values, needs, and preferences of patients have been meaningfully incorporated into value assessments is becoming an increasingly important consideration in value calculations. A standard definition of value and patient centricity in healthcare remains unsettled, yet incorporating patient perspectives into such assessments requires collaborative and consistent efforts. Neglecting this crucial aspect will only result in sporadic and superficial conversations with patients, failing to capture meaningful data that can foster a healthcare system which truly places them at the centre. Data, analysis, and a real world understanding of the covered population is imperative to really bring value to healthcare. Old practices that have created data silos, minimized the role of patients, fostered the wrong kind of competition instead of the right kind of collaboration have hindered progress in healthcare, resulting in slower development of new treatments, interventions and policies that have ultimately delayed the delivery of better care to patients.