IMPACT OF TREATMENT SUBSIDIES AND CASH PAY-OUTS ON TREATMENT CHOICES AT THE END OF LIFE

Purpose: This study uses a stated preference survey to examine the extent to which financial assistance, in the form of subsidies for life extending treatments (LETs) or cash pay-outs, distorts the demand for end-of-life treatments.

Method(s): A discrete choice experiment, consisting of 10 choice tasks, was administered to 290 patients with breast, lung or colorectal cancer (Stage I-IV) from outpatient clinics in Singapore to elicit their preferences for LETs and palliative care (PC) only. For each task, participants selected their most preferred scenario from two LET choices and PC only (sample task in Figure 1). Each task systematically varied in terms of net cost after cash pay-out (from a hypothetical insurance plan), median length of survival, 5-year survival rate and quality of life. Responses were fitted to a latent class conditional logistic regression model, accounting for potential preference heterogeneity among subgroups of participants. Based on estimated relative preferences, we quantified patients' willingness to accept a less effective LET or PC only. We then simulated the effects of various LET subsidy and cash pay-out policies on treatment choices.

Result(s): We identified 3 main classes of patients according to their end-of-life preferences (see Figure 2). The first class (26.1% of sample) has a strong preference for PC such that they are willing to give up gains in life expectancy and even pay for receiving only PC. The second class (29.8% of sample) has a strong preference for LETs and prefers to extend life regardless of cost or quality of life. The final class (44.1% of sample) prefers LETs to PC, but actively trades off costs, length and quality of life when making end-of-life treatment choices. Marital status and cancer type were found to be predictive of class membership. Policy simulations show that LET subsidies have a greater distortionary effect on treatment choices compared to a cash pay-out, which was not shown to distort demand for PC or LETs.

Conclusion(s): Cancer patients have heterogeneous end-of-life preferences. Unlike cash-pay-outs, LET subsidies distort relative prices of different treatments and encourage greater utilization of LETs. Policymakers should be mindful of these differences when designing healthcare financing schemes for patients with life-limiting illnesses.