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Integrative and complementary medicine among cancer patients: At what price?
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European Journal of Integrative Medicine 3 (2011) e139–e141
Opinion article
Integrative and complementary medicine among cancer patients: At what price? Aminah Jatoi Department of Oncology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA Received 18 November 2010; received in revised form 6 June 2011; accepted 6 June 2011
Abstract Cancer patients frequently utilize integrative and complementary approaches. Indeed, patients are paying as much as $34 billion a year out-ofpocket for such approaches in the United States. This review discusses whether such therapies are ever cost-effective, provides some data on how much money individual patients appear to be spending, and suggests general guidelines on how healthcare providers may want to broach such issues with cancer patients. © 2011 Published by Elsevier GmbH. Keywords: Cost; Integrative medicine; Cancer
Approximately $34 billion are spent each year on integrative and complementary medicine in the United States [1]. Reporting on 2007 data from the United States, Nahin and others provided a breakdown of this figure. These investigators found that the costs of the healthcare practitioner account for $11.9 billion [1]. An additional $14.8 billion are used by patients for the acquisition of non-vitamin and non-mineral natural products. Classes in yoga, tai chi, and qigong account for $4.1 billion, and homeopathic practices account for $2.9 billion. Relaxation techniques account for another $0.2 billion. Finally, self-care that utilizes integrative and complementary approaches accounts for the remaining $22 billion. Who is paying for all these interventions? The forgoing data refer only to out-of-pocket costs from both cancer and non-cancer patients and were obtained by means of surveys of non-pediatric patients. These data make the point that integrative and complementary therapies, such as those described above, can be expensive and that patients themselves are often covering the costs. The fact that patients themselves are willing to pay out-ofpocket for integrative and complementary approaches – many of which lack substantive proof of efficacy – underscores the need to probe further into the cost effectiveness of such integrative and complementary approaches. Thus, this review discusses the
E-mail address: [email protected] 1876-3820/$ – see front matter © 2011 Published by Elsevier GmbH. doi:10.1016/j.eujim.2011.06.005
following two questions. Are there any data to indicate that integrative and complementary medicine can be worth the cost for cancer patients? How should we as healthcare providers counsel cancer patients about the issue of cost? Is integrative and complementary medicine worth the cost? The National Center for Complementary and Alternative Medicine defines the above approaches as follows: “a group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine”. A major challenge in determining whether such interventions are worth the cost rests upon a dearth of data that allow us to determine the efficacy or the comparative efficacy of such approaches. A recent review by Ernst attempted to categorize such interventions based on cost and also based on perceived efficacy with respect to more standard interventions [2]. This investigator from the United Kingdom discussed acupuncture for nausea and vomiting, massage for anxiety, aroma therapy for the general palliation of cancer symptoms, as well as several other interventions. He concluded that the cost of integrative and complementary approaches varied markedly from one approach to another but that often times the efficacy of the conventional approaches was greater. This review draws two important points. First, in the absence of direct comparative data, such as phase III studies, this approach is the best that one can do. It helps patients and healthcare providers face this issue of cost even in the absence of more conclusive and rigorous data. Second, this review forces
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A. Jatoi / European Journal of Integrative Medicine 3 (2011) e139–e141
one to consider the true role of these integrative and complementary approaches. Although it appears that efficacy might be stronger at times with the use of conventional therapy, there nonetheless appears to be a role for integrative and complementary approaches. These approaches may provide a supplemental advantage when combined with conventional therapy, thereby empowering patients to make their own treatment decisions while, at the same time, giving them an extra advantage towards achieving more favorable clinical outcomes. Thus, when examining whether integrative and complementary approaches are worth the cost, conclusions may not always be black and white. Have any studies probed into whether integrative and complementary approaches might spare patients from utilizing conventional approaches and thereby cut back on overall costs? To our knowledge, a few studies have done so, and not all have suggested cost savings. However, two studies suggest that integrative and complementary approaches might save costs. Herman and others concluded [3], “CAM therapies may be considered cost-effective for migraine, neck pain, stress management. . .”. Similarly, Lind and others concluded [4], “Among insured patients with back pain, fibromyalgia, and menopause symptoms, patients who use CAM providers have lower insurance expenditures”. For example, Lind and others investigated insurance claims data within the State of Washington between 2000 and 2003. These investigators performed a patient-matched case control study to better examine expenditures. They observed that users of integrative and complementary medicine were paying $1219 annually for outpatient expenditures, in contrast to $1502 by non-users. Additionally, inpatient expenditures were $765 and $1178, respectively. Other expenditures included $1184 and $1473, respectively. Notably, $630 was spent specifically on integrative and complementary approaches. Although similar data have not been captured among cancer patients, the findings from Lund and others demonstrate a potential shift in medical care utilization from conventional to integrative and complementary approaches with the use of the latter resulting in overall lower healthcare costs. In other words, if a patient has back pain and utilizes an integrative and complementary approach that alleviates the pain, it becomes unlikely that that patient will subsequently require an MRI to assess his back pain. This ability to circumvent an MRI results in lower healthcare costs. Again, to our knowledge, such observations have not been reported among cancer patients, but the concept of shifting and saving costs in this manner seems plausible in medicine in general. It becomes unclear, however, whether such shifts benefit the patient who may at times be paying for integrative and complementary therapy out-of-pocket expenses or a third party payor who might have been paying only for the MRI scan that was not obtained. How should we as healthcare providers counsel cancer patients about the issue of cost? Clearly, the availability of funds predicts whether or not patients will use integrative and complementary therapies. Wolsko and others conducted a random household telephone survey of 2055 United States adults and observed that individuals who had full insurance coverage which included coverage of integrative and complementary approaches were almost 5 times more likely to utilize such integrative and
complementary approaches [5]. Along similar lines, Wyatt and others examined breast cancer patients – sometimes as many as 80% of these patients are utilizing integrative and complementary approaches; and these investigators focused specifically on 222 patients with early stage disease [6]. Wyatt and others observed a trend to suggest employment – or having a steady income – was positively predictive of whether integrative and complementary approaches would be used by a patient. This observation about availability of funds has important consequences. Although occasionally patients are able to receive some or partial insurance coverage to enable them to utilize such integrative and complementary approaches, often times patients are in fact paying out of pocket – and, although they might be able to afford such therapies early on – the continued use of such interventions might take a toll on one’s ability to keep paying. Previously, our group undertook a patient simulation exercise that was designed to investigate how much cancer patients are paying for nutrition-based integrative and complementary approaches [7]. We focused on utilizing the internet because many of these approaches are accessed and purchased on-line. Additionally, because many patients are reluctant to admit their use of integrative and complementary approaches to their healthcare providers, we thought a patient simulation exercise would be of value by circumventing this reluctance. Looking at a variety of such agents, our group observed that the cost of these approaches ranged from $4.33 to $263 per month. When one considers that patients often use more than one type of integrative and complementary approach, these costs can ultimately be quite substantial for a particular patient. How should we as healthcare providers help patients deal with such costs? First, it seems important not to ignore this issue, but to acknowledge to patients and families at the outset that the cost associated with these interventions can be substantial for some patients. Admittedly, talking about money matters with a patient is sometimes viewed as a taboo topic, but when one considers the patient- and family-related hardship that can be invoked by such costs, these discussions are warranted. Secondly, recognition of the cultural aspects of some integrative and complementary approaches is important. For some patients, the use of a nonconventional therapy is a foregone conclusion and very much in keeping with their cultural heritage. This cultural sensitivity can be of great importance during discussions with patients and their families. Thirdly, it is important to discuss cost and efficacy together. If there are absolutely no data to suggest that a costly integrative and complementary approach carries efficacy or if there are data to show that it does not, then it would be important to discuss with the patient that he may be spending money on an intervention that may not provide benefit. Finally, sometimes family members want to do everything they can for a loved one, and yet they simply cannot afford a particular integrative and complementary approach. Such circumstances can generate notable guilt. Talking about this issue and bringing this situation into the open can help patients and families better cope. Conflict of interest The author has no conflict of interest.
A. Jatoi / European Journal of Integrative Medicine 3 (2011) e139–e141
References [1] Nahin RY, Barnes PM, Stussman BJ, Bloom B. Costs of complementary and alternative medicine and frequency of visits to CAM practitioners: United States 2007. In: National Health Statistics Report. 2009. [2] Ernst E. Complementary and alternative medicine: what the NHS should be funding? Br J Gen Pract 2008 [March]. [3] Herman PM, Craig BM, Caspi O. Is complementary and alternative medicine cost-effective? A systematic review. BMC Complement Altern Med 2005;5:11. [4] Lind BK, Lafferty WE, Tyree PT, et al. Comparison of health care expenditures among insured users and nonusers of complementary and alternative
e141
medicine in Washington State: a cost minimization analysis. J Altern Complement Med 2010;16:411–7. [5] Wolsko PM, Eisenberg DM, Davis RB, et al. Insurance coverage, medical conditions, and visits to alternative medicine providers. Results of a national survey. Arch Intern Med 2002;162:281–7. [6] Wyatt G, Sikorskii A, Willis CE, An HS. Complementary and alternative medicine use, spending, and quality of life in early stage breast cancer. Nurs Res 2010;59:58–66. [7] Alsawaf MA, Jatoi A. Shopping for nutrition-based complementary and alternative medicine on the internet: how much money might cancer patients be spending online? J Cancer Educ 2007;22:174–6.
European Journal of Integrative Medicine 3 (2011) e139–e141
Opinion article
Integrative and complementary medicine among cancer patients: At what price? Aminah Jatoi Department of Oncology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA Received 18 November 2010; received in revised form 6 June 2011; accepted 6 June 2011
Abstract Cancer patients frequently utilize integrative and complementary approaches. Indeed, patients are paying as much as $34 billion a year out-ofpocket for such approaches in the United States. This review discusses whether such therapies are ever cost-effective, provides some data on how much money individual patients appear to be spending, and suggests general guidelines on how healthcare providers may want to broach such issues with cancer patients. © 2011 Published by Elsevier GmbH. Keywords: Cost; Integrative medicine; Cancer
Approximately $34 billion are spent each year on integrative and complementary medicine in the United States [1]. Reporting on 2007 data from the United States, Nahin and others provided a breakdown of this figure. These investigators found that the costs of the healthcare practitioner account for $11.9 billion [1]. An additional $14.8 billion are used by patients for the acquisition of non-vitamin and non-mineral natural products. Classes in yoga, tai chi, and qigong account for $4.1 billion, and homeopathic practices account for $2.9 billion. Relaxation techniques account for another $0.2 billion. Finally, self-care that utilizes integrative and complementary approaches accounts for the remaining $22 billion. Who is paying for all these interventions? The forgoing data refer only to out-of-pocket costs from both cancer and non-cancer patients and were obtained by means of surveys of non-pediatric patients. These data make the point that integrative and complementary therapies, such as those described above, can be expensive and that patients themselves are often covering the costs. The fact that patients themselves are willing to pay out-ofpocket for integrative and complementary approaches – many of which lack substantive proof of efficacy – underscores the need to probe further into the cost effectiveness of such integrative and complementary approaches. Thus, this review discusses the
E-mail address: [email protected] 1876-3820/$ – see front matter © 2011 Published by Elsevier GmbH. doi:10.1016/j.eujim.2011.06.005
following two questions. Are there any data to indicate that integrative and complementary medicine can be worth the cost for cancer patients? How should we as healthcare providers counsel cancer patients about the issue of cost? Is integrative and complementary medicine worth the cost? The National Center for Complementary and Alternative Medicine defines the above approaches as follows: “a group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine”. A major challenge in determining whether such interventions are worth the cost rests upon a dearth of data that allow us to determine the efficacy or the comparative efficacy of such approaches. A recent review by Ernst attempted to categorize such interventions based on cost and also based on perceived efficacy with respect to more standard interventions [2]. This investigator from the United Kingdom discussed acupuncture for nausea and vomiting, massage for anxiety, aroma therapy for the general palliation of cancer symptoms, as well as several other interventions. He concluded that the cost of integrative and complementary approaches varied markedly from one approach to another but that often times the efficacy of the conventional approaches was greater. This review draws two important points. First, in the absence of direct comparative data, such as phase III studies, this approach is the best that one can do. It helps patients and healthcare providers face this issue of cost even in the absence of more conclusive and rigorous data. Second, this review forces
e140
A. Jatoi / European Journal of Integrative Medicine 3 (2011) e139–e141
one to consider the true role of these integrative and complementary approaches. Although it appears that efficacy might be stronger at times with the use of conventional therapy, there nonetheless appears to be a role for integrative and complementary approaches. These approaches may provide a supplemental advantage when combined with conventional therapy, thereby empowering patients to make their own treatment decisions while, at the same time, giving them an extra advantage towards achieving more favorable clinical outcomes. Thus, when examining whether integrative and complementary approaches are worth the cost, conclusions may not always be black and white. Have any studies probed into whether integrative and complementary approaches might spare patients from utilizing conventional approaches and thereby cut back on overall costs? To our knowledge, a few studies have done so, and not all have suggested cost savings. However, two studies suggest that integrative and complementary approaches might save costs. Herman and others concluded [3], “CAM therapies may be considered cost-effective for migraine, neck pain, stress management. . .”. Similarly, Lind and others concluded [4], “Among insured patients with back pain, fibromyalgia, and menopause symptoms, patients who use CAM providers have lower insurance expenditures”. For example, Lind and others investigated insurance claims data within the State of Washington between 2000 and 2003. These investigators performed a patient-matched case control study to better examine expenditures. They observed that users of integrative and complementary medicine were paying $1219 annually for outpatient expenditures, in contrast to $1502 by non-users. Additionally, inpatient expenditures were $765 and $1178, respectively. Other expenditures included $1184 and $1473, respectively. Notably, $630 was spent specifically on integrative and complementary approaches. Although similar data have not been captured among cancer patients, the findings from Lund and others demonstrate a potential shift in medical care utilization from conventional to integrative and complementary approaches with the use of the latter resulting in overall lower healthcare costs. In other words, if a patient has back pain and utilizes an integrative and complementary approach that alleviates the pain, it becomes unlikely that that patient will subsequently require an MRI to assess his back pain. This ability to circumvent an MRI results in lower healthcare costs. Again, to our knowledge, such observations have not been reported among cancer patients, but the concept of shifting and saving costs in this manner seems plausible in medicine in general. It becomes unclear, however, whether such shifts benefit the patient who may at times be paying for integrative and complementary therapy out-of-pocket expenses or a third party payor who might have been paying only for the MRI scan that was not obtained. How should we as healthcare providers counsel cancer patients about the issue of cost? Clearly, the availability of funds predicts whether or not patients will use integrative and complementary therapies. Wolsko and others conducted a random household telephone survey of 2055 United States adults and observed that individuals who had full insurance coverage which included coverage of integrative and complementary approaches were almost 5 times more likely to utilize such integrative and
complementary approaches [5]. Along similar lines, Wyatt and others examined breast cancer patients – sometimes as many as 80% of these patients are utilizing integrative and complementary approaches; and these investigators focused specifically on 222 patients with early stage disease [6]. Wyatt and others observed a trend to suggest employment – or having a steady income – was positively predictive of whether integrative and complementary approaches would be used by a patient. This observation about availability of funds has important consequences. Although occasionally patients are able to receive some or partial insurance coverage to enable them to utilize such integrative and complementary approaches, often times patients are in fact paying out of pocket – and, although they might be able to afford such therapies early on – the continued use of such interventions might take a toll on one’s ability to keep paying. Previously, our group undertook a patient simulation exercise that was designed to investigate how much cancer patients are paying for nutrition-based integrative and complementary approaches [7]. We focused on utilizing the internet because many of these approaches are accessed and purchased on-line. Additionally, because many patients are reluctant to admit their use of integrative and complementary approaches to their healthcare providers, we thought a patient simulation exercise would be of value by circumventing this reluctance. Looking at a variety of such agents, our group observed that the cost of these approaches ranged from $4.33 to $263 per month. When one considers that patients often use more than one type of integrative and complementary approach, these costs can ultimately be quite substantial for a particular patient. How should we as healthcare providers help patients deal with such costs? First, it seems important not to ignore this issue, but to acknowledge to patients and families at the outset that the cost associated with these interventions can be substantial for some patients. Admittedly, talking about money matters with a patient is sometimes viewed as a taboo topic, but when one considers the patient- and family-related hardship that can be invoked by such costs, these discussions are warranted. Secondly, recognition of the cultural aspects of some integrative and complementary approaches is important. For some patients, the use of a nonconventional therapy is a foregone conclusion and very much in keeping with their cultural heritage. This cultural sensitivity can be of great importance during discussions with patients and their families. Thirdly, it is important to discuss cost and efficacy together. If there are absolutely no data to suggest that a costly integrative and complementary approach carries efficacy or if there are data to show that it does not, then it would be important to discuss with the patient that he may be spending money on an intervention that may not provide benefit. Finally, sometimes family members want to do everything they can for a loved one, and yet they simply cannot afford a particular integrative and complementary approach. Such circumstances can generate notable guilt. Talking about this issue and bringing this situation into the open can help patients and families better cope. Conflict of interest The author has no conflict of interest.
A. Jatoi / European Journal of Integrative Medicine 3 (2011) e139–e141
References [1] Nahin RY, Barnes PM, Stussman BJ, Bloom B. Costs of complementary and alternative medicine and frequency of visits to CAM practitioners: United States 2007. In: National Health Statistics Report. 2009. [2] Ernst E. Complementary and alternative medicine: what the NHS should be funding? Br J Gen Pract 2008 [March]. [3] Herman PM, Craig BM, Caspi O. Is complementary and alternative medicine cost-effective? A systematic review. BMC Complement Altern Med 2005;5:11. [4] Lind BK, Lafferty WE, Tyree PT, et al. Comparison of health care expenditures among insured users and nonusers of complementary and alternative
e141
medicine in Washington State: a cost minimization analysis. J Altern Complement Med 2010;16:411–7. [5] Wolsko PM, Eisenberg DM, Davis RB, et al. Insurance coverage, medical conditions, and visits to alternative medicine providers. Results of a national survey. Arch Intern Med 2002;162:281–7. [6] Wyatt G, Sikorskii A, Willis CE, An HS. Complementary and alternative medicine use, spending, and quality of life in early stage breast cancer. Nurs Res 2010;59:58–66. [7] Alsawaf MA, Jatoi A. Shopping for nutrition-based complementary and alternative medicine on the internet: how much money might cancer patients be spending online? J Cancer Educ 2007;22:174–6.