2012 Conference
Defining Value in Cancer Care... fact that most of the revenue for oncology practices comes from the margin on drugs. If we are going to make the decisions about which treatments to use on which patients as cost-neutral to the practice, we have to reward those innovative practice models and start to reimburse providers for offering care that is patient-centered and well-coordinated rather than reimbursing them for selecting the most expensive, highest technology-based novel therapy, if that therapy is not going to have a dramatic improvement in patient outcomes. Dr Beed: What do you think about the way we pay oncologists, and the incentives that are a part of it? Dr Mitchell: I am unable to think of another specialty that brings in revenue based on billing for drug therapy to the degree that is done in oncology. Part of the elephant in the room is the potential for treatment decisions, and more specifically medication selection, based on potential clinic revenue. One possible solution is to reevaluate the way cancer centers are reimbursed. One option would be allowing a management fee, similar to a medical home but more comprehensive, because the sophisticated centers do have interdisciplinary teams. Knowing that it costs more to deliver that type of care, this removes the revenue out of the drug side completely, and puts it into a management fee. Dr Beed: We have mentioned personalized medicine: what do payers think of this approach? Are they going to only pay for people who have the biomarker? Does personalized medicine direct therapy, or do people just become a little more comfortable or a little less comfortable with what they have decided they are going to do? If all we have done is add the cost of a test, that really did not change anything. Is personalized medicine the Holy Grail? Are we going to test for biomarkers in everyone? Dr Beveridge: One of the main problems is that with International Classification of Diseases, Ninth Edition (ICD9) coding, the insurers do not know whether a patient with lung cancer had small-cell or non–small-cell lung cancer, localized versus metastatic, first-line therapy or fifth-line therapy. Payers were in the dark. In the next couple of years, ICD-10 will address some of that. The inability to compare groups throughout the country has been a fundamental problem in terms of assessing quality in one area versus the other. Peter Ellis, MD, Kathy Lokay, and others
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first started using pathways, and then the US Oncology Network and McKesson Specialty Health have continued with pathways in the past 7 years. I suspect that some of the criticism that
At some point we need to address the issues of end of life, corporate use of hospice, and futile therapy. These are all crucially important for the management of the patient. That is what we should discuss when we talk about true patient-centered principles and personalized medicine. —Roy A. Beveridge Dr Ellis remembers is that we (the US Oncology Network) were converting over to “cookbook medicine,” that all people were being treated the same, and that the goals of pathways were to render the least expensive care. As we look at the evolution of pathways in the past 6 to 7 years, we recognize that it allows for true personalization of care. Because the treatment algorithm does specify, and probably all pathways in the country do now, whether this is for a patient with breast cancer who is HER2-positive, HER2-negative, estrogen-receptor–positive, triple-negative, and so on. But this is not the “be all and end all” as far as where we need to go. In terms of truly personalized care, the answer is more than just pathways. We need to begin to take into account radiation, which we have not yet discussed. Today, radiation is a significant component of our cancer care delivery system. We keep talking about drugs, because most of us are medical oncologists, but hospitalization and emergency department rates are very important in terms of costs. At some point we need to address the issues of end of life, corporate use of hospice, and futile therapy. These are all crucially important for the management of the patient. That is what we should discuss when we talk about true patient-centered principles and personalized medicine.
VALUE-BASED CANCER CARE
Dr Vogenberg: I have recently had
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discussions with employers about personalized medicine. One of the common responses I hear is, “If you cannot prove or show me that what you are doing is better than what we did before using a newer product versus an older product, then the only difference is cost.” All of these other quality parameters we talk about are considered to be irrelevant by the true payer (ie, the employer as benefits purchaser). We have seen this with CMS, and we are seeing it now with employers. I have never heard an employer say, “I’m not willing to pay.” All employers are willing to pay, but they want to see that this cost is making a difference. That value is going to be key to the focus of personalized medicine. We are increasingly moving toward personalized medicine, which will be a large conundrum. A key issue will be whether we can differentiate between the performance of one product and all of the surrounding services. Dr Sprandio: Ultimately we are going to get to a point where we are using genomic diagnosis. But with tumor genomics sequencing, any escape mechanism creates a significant challenge for the oncologist in trying to decide how to use that wealth of information to figure out which therapy is best. And there are probably going to be a number of tumors for which no markers exist.
We can most likely all accept that our current system is not sustainable. If we look to the past, at least in the area of cancer treatment, some fairly dramatic mistakes were made when it came to value and cost. We cannot continue to make these types of mistakes, but we continue to make them. —Craig K. Deligdish
Dr Deligdish: Payers think there is value in information related to clinical utility, if that information helps the physician to decide on an optimal therapy. But if this information does not help
in the decision-making process, then that information has limited value. For example, if the cost of tumor genome sequencing is in the $2000 range in the next several years, and the cost of treatment is between $5000 and $15,000 monthly, the cost of genome sequencing may be a good investment if it impacts the decision-making process. However, if some patients can be cured by the information gleaned from this test, the value may be priceless. We can most likely all accept that our current system is not sustainable. If we look to the past, at least in the area of cancer treatment, some fairly dramatic mistakes were made when it came to value and cost; one example is the use of high-dose chemotherapy and autologous bone marrow transplantation for women with breast cancer. That treatment was very popular and was even performed at tertiary medical centers and in the community setting. Indeed, billions of dollars were spent before it was recognized that the treatment had no true value and was associated with significant morbidity and mortality. Similar examples occurred in the past couple of years, when treatments that were promoted without proven benefit were approved and implemented on a fairly large scale. We cannot continue to make these types of mistakes, but we continue to make them. As we move toward healthcare reform, we continue to see consolidation in the number of providers and payers. But as we continue with this consolidation, we are realizing that it does not reduce cost and does not make the system more efficient. Indeed, it makes the system less efficient and more costly. Unless we, as a society, are willing to address those issues, we will end up in a place where there probably is only 1 payer, because no other payers will be able to afford to be in that space, and patients may no longer be able to afford treatment. We need to think about where we are going to be in 5 years, because, as Dr Newcomer said, we cannot afford to be where we would end up in 10 years unless some of these issues are addressed. Dr Beed: If we are going to spend more money on cancer, how are we going to finance it? Are we going to spend less money on other diseases, hold down innovation, or borrow from the next generation? What are the appropriate steps, that could be accepted by providers, that we have to take as a society? Dr Silver: I have heard at an oncology panel that we spend more money on Continued on page 27
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