Our patients want to discuss cost of care with us. They want to know out-of-pocket costs before starting treatment.
—Neal J. Meropol, MD
We are optimizing a tool that a physician would have at his or her disposal in the office that would help patients understand what are the possible regimens, what are the ups and downs, and [how to] integrate those with their personal preferences.
—Lowell E. Schnipper, MD
The value proposition in health care is often represented with the following equation: Value = Outcomes/Cost. The simplicity of this equation, however, belies the complexity of its parts, which are the contributions of multiple stakeholders with unique perspectives.
A session presented at the 2015 ASCO Annual Meeting addressed these differing perspectives—the physician’s, the payer’s, the patient’s, and ASCO’s own value initiative—on the financial challenges in cancer care.1-4 If there are common denominators, they are the recognition of the need for change and the acknowledgment that achieving it will be anything but easy.
The Physician Perspective
“Oncologists won’t be gatekeepers based on cost. But oncologists do have the opportunity to become gatekeepers based on value in helping our patients choose between different therapies that may have the same cost but different value,” said Neal J. Meropol, MD, Chief of Hematology and Oncology at University Hospitals Case Medical Center and Case Western Reserve University, Cleveland.
This is an opportunity borne of necessity. As Dr. Meropol explained, the rising costs of drugs and medical services coupled with high-deductible insurance plans have combined to make cancer a financial, as well as a physical, hardship.
“The out-of-pocket burden on cancer patients is enormous,” he said. “Regardless of the type of insurance that you have, the financial burden tends to be greater with a cancer diagnosis than with other chronic diseases.”
According to Dr. Meropol, this burden can directly impact patient outcomes. Patients who have to pay more for a potentially lifesaving therapy are less likely to be compliant, he said, a correlation that contributes to disparities of care. There is, in fact, a limit to what patients are willing and able to pay for their survival; demand for cancer therapy is more elastic than once believed.
“Annual household income and whether or not a patient is working directly affect their stated preference for therapy,” Dr. Meropol reported. “Patients who are out of work are more likely to favor low-cost therapy than patients with higher incomes.” In Dr. Meropol’s opinion, better value begins with improved communication.
“Our patients want to discuss cost of care with us,” he said. “They want to know out-of-pocket costs before starting treatment, and in many cases, they would like their doctor to know how much they’re spending themselves on their cancer treatment.”
The creation of new payment models is also critical so that physicians are rewarded for the quality of their care, not the volume of services they provide.
Most of all, though, Dr. Meropol stressed the need for discussing the relative value of different treatment options with patients at the point of care. “I would love to have models and decision tools that would help me predict the benefits and toxicities for my individual patient, and I’d like to know, in real time, the anticipated out-of-pocket costs for my patients based on their insurance…. In this way, I might help them make the best decision based on their understanding of the value of the treatment options,” he concluded.
The Payer Perspective
According to Jennifer Malin, MD, PhD, Staff Vice President of Clinical Strategy, Anthem, Inc., delivering value to a multitude of stakeholders requires consideration of future patients, not just the ones making treatment decisions. This means factoring the total cost of care, including next year’s insurance premiums and out-of-pocket costs.
“Patients are making decisions way before they ever get diagnosed with cancer that impact their out-of-pocket costs and what they choose. If they pick a high-deductible plan because they can only afford low premiums, that leaves them in a situation of facing much higher out-of-pocket costs,” she said.
In Dr. Malin’s opinion, the key to understanding value lies in the negotiation of clinical benefit, toxicity, and cost. An initiative called the Cancer Care Quality Program is Anthem’s attempt to evolve the current health-care model and reward practices that pursue high-value care.
“What a pathway does is try to identify the most high-value regimens and put them out there as a benchmark,” she explained. “Oncologists participating in the Cancer Care Quality Program will receive additional payment for treatment planning and care coordination when they select a treatment regimen that is on pathway.”
Ultimately, said Dr. Malin, it is the payer’s responsibility to balance the needs of several stakeholders at different points in time; the pathway model is one part of the solution.
“It’s important to think about value from the position of all stakeholders,” she concluded. “We need to have quality and affordable cancer care, reimbursement needs to be aligned for providers so they can achieve desired outcome, and we need to encourage clinically meaningful therapeutic innovations.”
The Patient Perspective
Despite the mounting costs of cancer care and bankruptcy rates for patients with cancer that are nearly twice the general population’s, according to one breast cancer advocate, when patients are asked to define value in the context of their care, cost is not their first concern.
“If you push patients to share [their thoughts] about value in the context of cancer treatment, they invariably refer to communication and the relationship with the doctor as being paramount,” said Beverly E. Canin, Vice President of Breast Cancer Options, Inc.
A survey shared by Ms. Canin revealed that only 7.5% of patients defined value in terms of an exchange. On the other hand, more than 38% of patients defined value in terms of a personal value. Financial cost relative to benefit or treatment efficacy was rarely mentioned, she observed.
“When we are in your office or clinic in treatment, we care the most about our relationships and trust with you, our doctors…. I speak of ‘we,’ but we patients are not some all-inclusive single entity. The ‘we’ is a collective of individuals that must be seen, communicated with, and treated as individuals,” she concluded.
ASCO Value Initiative
According to the Chair of the ASCO Task Force on Value in Cancer Care, Lowell E. Schnipper, MD, ASCO’s vision is to provide all patients with lifelong access to affordable, compassionate, and high-quality care. Accomplishing this feat, however, involves rethinking how oncologists value treatment options so they can help patients make informed decisions.
“Ultimately,” said Dr. Schnipper, Chief of Hematology/Oncology and Clinical Director of Beth Israel Deaconess Medical Center, Boston, “we are optimizing a tool that a physician would have at his or her disposal in the office that would help patients understand, for a given clinical indication, what are the possible regimens, what are the ups and downs, and [how to] integrate those with their personal preferences.” (For more information on ASCO’s Task Force on Value in Cancer Care, see the June 25, 2015, issue of The ASCO Post.) Dr. Schnipper foresees the day when a tool such as this might be incorporated into decisions that health-care systems might make in striving to provide patients with high value cancer care.
The value framework developed by the task force is designed to compare a standard-of-care therapy with a new regimen (or single agent) and distinguishes between small or large improvements when compared to the standard of care for overall or progression-free survival and palliation of symptoms in advanced disease. Comparisons of toxicity of the standard of care and test regimens are weighed as well, and the sum of clinical benefit and toxicity is then derived to yield a net health benefit of the test regimen when compared with the standard of care.
Finally, cost was an unavoidable variable in the value conversation, a critical emphasis of discussion at the physician-patient interface. “As the cost of care increases, I’m not talking about the U.S. economy,” he said. “I’m talking about the patient sitting across from you. People exhaust their savings so their kids may have to delay going to college. Second mortgages on the house are taken, and adherence to the medication is shown to be reduced.” ■
Disclosure: Dr. Meropol is a consultant for BioMotiv. Dr. Malin is an employee and shareholder of Anthem, Inc. Dr. Schnipper is a member and on the advisory board of Eviti, Inc; and is Co-Editor-in-Chief of UpToDate Oncology.
1. Meropol NJ: The physician perspective: The value proposition in oncology: Different approaches to understanding value in cancer care. 2015 ASCO Annual Meeting. Presented May 29, 2015.
2. Malin J: Case considerations: Value from the payer perspective. 2015 ASCO Annual Meeting. Presented May 29, 2015.
3. Canin BE: Patient priorities on value in treatment choices. 2015 ASCO Annual Meeting. Presented May 29, 2015.
4. Schnipper LE: Assessing value in cancer care: An ASCO initiative. 2015 ASCO Annual Meeting. Presented May 29, 2015.