Oncologists have an obligation to avoid unneccessary testing and to prescribe the lower-cost option if it is equivalent to a more expensive drug.
—Ezekiel J. Emanuel, MD, PhD
It’s difficult for oncologists to be gatekeepers on cost, but they should become gatekeepers for value.
—Neal J. Meropol, MD
Judging from its visibility at the 2014 ASCO Annual Meeting, the concept of “value” in cancer care has reached critical mass.
“ASCO is leading this difficult discussion on value in cancer care. This had to happen,” said Clifford A. Hudis, MD, FACP, Immediate Past President of ASCO and Chief of the Breast Medicine Service at Memorial Sloan Kettering Cancer Center, New York.
At the ASCO session, “Can We Find Common Ground? Stakeholder Perspectives on Value in Cancer Care,” representatives from the oncology clinical community, health-care payers, industry, and patient advocacy groups offered insights from around the value equation, but the bottom line was unanimous: With 30% of the average $50,000 (approximate median) household income now spent on health care, the trend is unsustainable and a solution is urgently needed.
Ezekiel J. Emanuel, MD, PhD, Diane v.S. Levy and Robert M. Levy University Professor, Professor of Health Care Management, and Professor of Medical Ethics and Health Policy in the Perelman School of Medicine and The Wharton School at the University of Pennsylvania, Philadelphia, noted that the United States spent $3 trillion on health care in 2013. “That’s larger than the economy of France,” he pointed out. An estimated 5% of this total—$150 billion or more—goes to cancer care, amounting to 10 times the “pockets” of the five largest insurance companies, he added.
“The high cost of cancer care threatens to increase disparities in care and outcomes,” added session Chair Neal J. Meropol, MD, Chief of Hematology and Oncology at University Hospitals–Seidman Cancer Center and Case Western Reserve University, Cleveland.
These costs are incurred in multiple ways—through lack of insurance, copays/coinsurance, tiered formularies, the Medicare part D “donut hole,” and oncology drug shortages—but perhaps most sensationally by the cost of new agents, as illustrated by five new drugs that were approved in 2013 (Table 1).
Dr. Emanuel noted that even older, established agents are getting more expensive. The price of imatinib (Gleevec), for example, has tripled since it first reached the market, despite the launch of competitors.
Not Just About ‘Value’
While the world expects therapeutic breakthroughs, the fact that significant amounts of money are spent for small gains is becoming universally unacceptable. The controversy is not just about “value” but about “cost,” Dr. Emanuel maintained.
“If you doubt that, look at the new drugs for hepatitis C. We are talking about $80,000 for a disease cure, and it’s still controversial. Any educated person would acknowledge that a one-time curative treatment is good value, yet there is still consternation,” Dr. Emanuel observed. “Yes, we are concerned about value, but we are also concerned about absolute total costs.”
Oncologists Need to Do More
Total cost is determined by multiplying price times volume, Dr. Emanuel said, and oncologists have some control over both. He suggested that oncologists examine both the volume and the price of their cancer interventions. Many may be guilty, he suggested, of being poor stewards of the cancer care budget through unnecessary testing, frequent use of drugs off label and off guidelines, and prescriptions for expensive drugs when less expensive ones are available.
Advanced gastric cancer is a good example of the wide variation in cost and in practice, he said, as there is a 50-fold difference in the price of the National Comprehensive Cancer Network’s preferred regimens.
“We have to ask ourselves what do we have to do with this story?” Dr. Emanuel continued. “Oncologists have an obligation to avoid unnecessary testing and to prescribe the lower cost option if it is equivalent to a more expensive drug. And we have an obligation to expose practices that are not adding value,” he said.
“I remind you, your patients are paying for this, and you are paying for this with increases in insurance. We all are—it is not a victimless crime,” he commented.
Much of the reticence over cutting costs pertains to the current reimbursement formulas, he pointed out. “We won’t get out of this box unless we stop paying doctors for testing more and giving more treatments. We have an obligation to advance off the fee-for-service model. And we should want to get out of this system so we can focus on patients, and actually spend time talking with them, as we claim we want to do. We can’t reach common ground until we have payment reform, but between now and then, we need to do our part.”
ASCO Is Addressing Value
ASCO is beginning to address the issue of value, according to Lowell E. Schnipper MD, Berenson Professor in Medicine, Harvard Medical School, Chief of Hematology/Oncology at Beth Israel Deaconess Medical Center, Boston, and Chair of the ASCO Task Force on Value in Cancer Care.
The problem is not so much the absolute dollars expended, but what these dollars buy for the patients who may be experiencing financial as well as physical toxicity, Dr. Schnipper suggested. “It’s what we are buying, and not buying, with the health-care dollars that we expend,” he said. “The amount of overuse and waste in the system is astonishing. We are not getting enough for the money.”
ASCO is now addressing the multiple elements that comprise value: unwanted variation in quality and outcome, harm to patients, waste and failure to maximize value, health inequalities and inequities, and failure to prevent disease. Efforts are underway through the Quality Oncology Practice Initiative (QOPI), CancerLinQ, the Choosing Wisely campaign, and participation in experimental models of payment reform.
In addition, ASCO’s Value Initiative is seeking to create a transparent, clinically driven, methodologically sound method for defining and assessing relative value of cancer care options. “We want to give oncology providers the skills and tools to assess the relative value of therapies and use these in discussing treatment options with patients,” Dr. Schnipper said.
Such a tool would describe different clinical scenarios, treatments, benefits, toxicities, and costs, producing a formula for treatments that have no value, low value, medium value, or high value—with nuance and distinguishability among regimens. The ultimate results would be a “score” that is proportionate to the degree of benefit.
Value-Based Insurance, Site of Service
Payers are certainly committed to furthering value in cancer care, added Lee N. Newcomer, MD, MHA, Senior Vice President of Oncology, Women’s Health and Genetics for UnitedHealthcare. “We have to start having discussions about value, and we are going to have to say that there are certain things that should not be covered. The issue is how to do this in a way that will be rational and fair,” he said.
Copays were never intended to be large enough to keep patients from receiving important, high-value care, but to keep them from selecting lower-value care, Dr. Newcomer explained. The idea was for the patient “to pause and ask, ‘Is this worth the money?’” he said. In many situations, patients don’t think so, he noted. His company has documented a 58% compliance rate among patients with $50 copays for a $5,000-a-month drug. “That’s concerning to me,” he commented.
A value-based insurance design would create a fair differential between high-value services and low-value ones. A high-value service might offer complete coverage, with no requirement for the patient’s financial participation, while a low-value service would mandate that the patient contribute, say, one-third or one-half—even 100% if the procedure lacks proven value.
The challenge will be in establishing meaningful, nonbiased thresholds, creating computer programs that can handle the complexity, and educating patients. “Where do we say that one thing should be free, and another should have 30% participation?” Dr. Newcomer asked. “No matter where we draw the line, someone will be unhappy.”
Trying to make this concept understandable to consumers—helping them discern the value of a given treatment—is expected to be a major barrier to getting value-based insurance in place, he predicted.
Dr. Newcomer also discussed site of care as an important component of value, indicating that the shift in cancer care from community practices into hospitals is an obstacle that is already costing the commercial payers a lot of money.
UnitedHealthcare pays the Centers for Medicare & Medicaid Services (CMS) rate plus 22% for chemotherapy delivered in the oncologist’s office. When the same chemotherapy is delivered by the same oncologist practicing in a hospital-owned facility, the company pays the CMS rate plus 146%—nearly seven times more for the same service, he noted.
Working Together to Find Solutions
Dr. Meropol suggested the tasks ahead for the major stakeholders include the following:
“It’s difficult for oncologists to be gatekeepers on cost, but they should become gatekeepers for value,” he said. ■