Association Between Spending and Outcomes for Patients With Cancer

Health care spending and health outcomes vary markedly across countries and even across regions within the United States.^1,2 This inevitably raises questions about whether higher spending is “worth it” in terms of better health outcomes.^3–6 Regional comparisons within the United States suggest that higher health care spending—especially at the end of life (EOL)—is not associated with better health outcomes. Medicare enrollees in higher spending regions receive more care but do not seem to live longer or otherwise experience better health outcomes,⁷ although the Medicare data suggest more waste than what is seen in younger, privately insured populations.⁸

Internationally, higher total and per capita health care spending in the United States is well documented and has persisted for many years.^9,10 This has fueled research attempts to assess whether additional health gains exist in the United States to justify this higher spending.^11,12 Results from these studies generally attribute the higher spending to higher prices,^13,14 greater utilization,¹⁵ or both,¹⁶ but these broad comparisons mask important heterogeneity by disease.¹¹

Perhaps nowhere is this issue more acute than in cancer. The United States spends more on cancer care than any other country and places at the top, or very near the top, of most international league tables for cancer outcomes.^11,17 Within the United States, we have seen a sizable reduction in cancer mortality in the past two decades but at significant cost. Overall cancer spending increased from $27 billion in 1990 to $137 billion in 2017 and is projected to increase further through 2020.^18–20

This rapid growth has motivated much scrutiny of cancer spending and its association with outcomes. It has also led to experiments with alternative payment and care delivery models in oncology.²¹ The fundamental question behind these debates and reforms is the relationship between spending and outcomes: Does spending improve outcomes in cancer, and if so, when? Existing evidence suggests that while some treatments, such as targeted cancer therapies, can improve outcomes, many others, such as chemotherapy overuse at EOL, fail to demonstrate such benefit.^22,23 Therefore, the association between spending and outcomes in cancer may not always be positive. For a conceptual framework of the effect of spending on health outcomes, see Martin et al.²⁴ To shed some light on this, we reviewed and synthesized the evidence both within the United States and internationally.

The full study can be read at the Journal of Clinical Oncology.