The best approach to delivering value-based care is by subtraction, getting rid of waste. If a service or drug’s absolute benefit cannot be backed up by data, it should not be delivered.— Keith D. Eaton, MD, PhD
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Over the past few years, the term value-based cancer care has become integrated into the vernacular of the oncology community. Value is a subjective term, which is defined largely by its clinical setting. However, value in cancer care is evaluated by the multiple stakeholders involved in the continuum of care, from detection to treatment. To shed light on this issue, The ASCO Post recently spoke with lung cancer specialist Keith D. Eaton, MD, PhD, a medical oncologist specializing in thoracic and head and neck cancers at the University of Washington/Seattle Cancer Care Alliance. Although he has a number of administrative titles at the Seattle Cancer Care Alliance, including Medical Director of Pharmacy and Infusion, his primary role is Medical Director for Quality, Safety, and Value.
Factoring in Quality of Life
Assessing value in cancer care is a subjective process. On a universal scale, is value measured by outcomes?
Traditionally, outcomes have been measured by survival. Michael E. Porter, PhD, one of the leaders in this field, says quite simply that value is what matters to patients. And for most patients, their overall survival with an acceptable quality of life is what matters most. There are some patients who tell their doctors that survival at any cost to their quality of life is their desired outcome. However, most people still factor quality of life into their ultimate decision. The patient’s perception of their quality of life is also important, and what informs that the most is the quality of the care that’s being delivered.
Streamlining the Process
How do we provide a way to ensure that as many patients as possible receive what they perceive as high-value care?
The first way is to make it as seamless as possible. Often, a patient’s experience from diagnosis, which can be a seesaw process, through staging and treatment planning can run the gamut of different specialists, all offering different options; then there’s travel and wait time, all of which creates a tremendous amount of anxiety for a new patient. So the trick is to have a systematic approach that simplifies and streamlines the process. And the treatment plan should carefully analyze each patient’s needs and make it as easy as possible for his or her particular lifestyle.
An Unfair Burden for Physicians
Many new expensive cancer drugs approved by the U.S. Food and Drug Administration confer survival of a couple of months, not including quality-of-life metrics. It might be meaningful to patients, but do those drugs bring value to our overburdened system?
As an oncologist, my primary goal is doing whatever I can to help my patients, regardless of costs. That’s the contract, if you will, we have in this country with our patients. In many other countries, however, it is explicit that doctors also have a duty to society at large in their decision-making as stewards of limited health-care resources. In the Canadian and British heath-care systems, for example, both efficacy and cost are factored into the decision of whether or not to cover a given therapy. These decisions are made by governmental agencies, not individual physicians. That’s not the ethos in the United States.
That said, I’ve spoken about the outcomes side of value, but there are also costs, which up until fairly recently, have been kept out of the value discussion. I think that one of the reasons for this reluctance to discuss cost is that our health system doesn’t really reflect a free-market system, in that our patients usually only see a fraction of the cost of their care. And they have no published metrics, like a consumer’s guide for instance, to measure the quality of care from place to place.
On top of that, the government, despite a few pilot projects in the Affordable Care Act, does not use comparative cost-effectiveness measures to assess the value of cancer drugs. Assessing costs is an unfair burden for individual doctors; it is an issue that needs to be addressed on a societal level.
There’s another issue at hand that rarely gets the attention it deserves in the cost-value discussion and that’s our fee-for-service payment system. It is an incentive for the provider to do more services, which leads to waste in the system. The value-based reimbursement model tries to align all the stakeholders’ interests.
Therefore, the best approach to delivering value-based care is by subtraction, getting rid of waste. If a service or drug’s absolute benefit cannot be backed up by data, it should not be delivered.
The Role of Payers
Payers are increasingly getting more involved in ensuring that their providers are delivering value-based cancer care. In a nutshell, what role can payers play in this issue?
Payers play a role in value-based care by developing risk-sharing models, in which the provider, hospital, and payer agree to a preestablished standards of acceptable usage and charges, sharing the gains and losses of a predefined patient population. This is one of the more popular approaches to addressing the increasing costs of cancer care.
In short, payer-generated models try to reduce cancer drug costs and cancer-related emergency room and hospitalization visits, which represent an increasing proportion in expenditures in cancer care.
Evidence-Based Pathways
As the number of therapeutic options for lung cancer quickly expands, how do we balance value-based decisions within the difficult clinical scenarios oncologists face?
At our center, we focus on minimizing treatments that do not offer evidence-based efficacy. Pathways can help to reduce the costs associated with advanced imaging, diagnostic tests, and drugs. For instance, at our institution pathways for thoracic malignancies have been created by a consensus process using tiered criteria: first around efficacy, second around toxicities, and finally around cost.
Overuse of advanced imaging is one area that we’ve looked at to trim waste and add value. There are data demonstrating that patients with lung cancer who received positron-emission tomography (PET) scans in their surveillance management did no better than those who did not receive such scanning. Although PET is covered, beyond use for staging, it has a limited role in lung cancer.
Also, in lung cancer, there are agents that have activity and decrease tumor size but haven’t shown a survival benefit. Often, providers will turn to these drugs after all other choices have been exhausted. But since they’re not backed by evidence, they should be avoided. Unfortunately, these options are sometimes used as a substitute for having a difficult conversations about end-of-life care rather than continued chemotherapy.
Moreover, studies have showed that early intervention with palliative care increases patient satisfaction and adds value to the care. In the overall discussion of value, we need to understand that high-value cancer care will optimize patient outcomes relative to cost. ■
Disclosure: Dr. Eaton reported no potential conflicts of interest.
