Oncology, with its numerous expensive therapies and increasing number of patients, contributes considerably to increasing health care expenditures.1,2 The benefit of these new cancer treatments varies from highly relevant improvements in outcome to effects of which the relevance for clinical practice has been a subject of controversy within and outside oncology.3,4 In fact, the field of oncology has been criticized for its spiraling costs that exceed the financial scope even of health care systems in high-income countries.3,5,6 The oncology community and society in general are, therefore, called on to confront the questions of what should count as a benefit in cancer care and how to set limits in a fair and justifiable way. Setting limits also means to withhold beneficial care (ie, ration treatments). If rationing is inevitable, a broad consensus exists that an explicit, rule-based rationing process is preferable to implicit, case-based rationing at the bedside.7-9
In Germany, tight budgets have been imposed on the inpatient and outpatient sectors. In short, inpatients of both statutory and private health insurances are reimbursed per case according to a system of diagnosis-related groups, with extra payments for some expensive procedures or drugs. Furthermore, the total budget of a hospital is limited and must be negotiated with the insurers. Outpatients in oncology are treated either in private practice or in outpatient clinics. In both cases, reimbursements are mainly per procedure. Reimbursements of costs for medicaments are compared with benchmarks according to the respective medical specialty. Moreover, in case of “off-label” use (a frequent situation with new cancer drugs), reimbursement either must be negotiated with third-party payers in advance, or remuneration may be endangered and redemption may be claimed from the prescribing physician. Explicit measures of rationing have only been adopted for a limited set of procedures and medications, none of them of high relevance for the therapy of life-threatening diseases (eg, limitations of coverage in dentistry and for over-the-counter drugs).
Empiric studies in the fields of cardiology and intensive care report actual bedside rationing in Germany.10 However, to the authors' knowledge, no data exist from quantitative studies, and only few data are available from qualitative studies that analyze bedside rationing in oncology.11 Moreover, review of the international literature indicates that, although a few studies analyzed the views and attitudes of oncologists about costs and cost/benefit, data are scarce on the prevalence of bedside rationing, with no special focus on oncology.12,13
This article presents data obtained from a survey of German Society of Hematology and Oncology (DGHO) members, which had the goal of acquiring information about the prevalence of withholding expensive treatments, typical examples, and rationales behind these decisions.
The authors have disclosed that they have no financial interests, arrangements, affiliations, or commercial interests with the manufacturers of any products discussed in this article or their competitors. Dr. Krause has received honoraria from Gilead, Takeda Pharmaceutical Company Limited, Hoffmann-La Roche Inc., Merck Sharp & Dohme Corp., GlaxoSmithKline, and Alexion Pharmaceuticals in the recent 12 months. Dr. Lotze has received honoraria from Baxter. Dr. Winkler has received an honorarium from Amgen. Dr. Schildmann has declared no potential conflict of interest.
The authors wish to thank all German Society of Hematology and Oncology (DGHO) members who responded to the questionnaire; the DGHO administration office (especially M. Renz) for logistic support; and the DGHO for funding the online questionnaire. Furthermore, they wish to thank D. Strech for providing the original questionnaire from his intensive care study and for participating in the very helpful discussions during the designing of the current survey, and all colleagues who commented on the preliminary versions of the questionnaire.
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