A Call for More Data Being Available to Providers
The delivery and receipt of cancer care in value-based healthcare models was the subject of a roundtable discussion at the National Comprehensive Cancer Network (NCCN) 23rd Annual Conference.
During the roundtable, panel members addressed the progress being made in achieving greater value from oncology care, the high costs that continue to burden patients, and the desire for access to comparative data. Clifford Goodman, PhD, senior vice president at the Lewin Group in Falls Church, VA, served as the moderator.
Financial Burden Impedes Access
Financial toxicity has become a concern to oncologists, as patients are faced with large deductibles and copays and often seek alternatives to costly therapies, said Daniel Mirda, MD, who is on the executive board at the Association of Northern California Oncologists. "Sometimes the best option is the most expensive option, and we have to look for second choices that are less expensive," he said. In this way, financial toxicity impedes access to the best care.
Travis Bray, PhD, founder of the Hereditary Colon Cancer Foundation, Portland, OR, noted that 78% of cancer survivors report moderate to catastrophic financial burden, "and that's continuing to go up." The for-profit system as it stands is aligned to generate value for the pharmaceutical industry but not necessarily patients, he said. Although guidelines for drug therapies are generally being followed by payers, those for prevention are getting short shrift, he maintained. About 10% of cancer is preventable if genetic testing is conducted before the development of cancer, but often the tests are delayed until after cancer develops.
Improving Value in a Cost-Conscious Market
A more collaborative interaction between insurers and providers is driving value, said Bhuvana Sagar, MD, lead medical director for specialty care collaborative and value-based reimbursement in oncology at Cigna. These collaborations are leading to decreases in inpatient and emergency department utilization and earlier use of palliative care; however, the improvements have been realized mostly in the space of large provider groups. Providers with smaller volumes tend to have higher costs because of increased volatility, "so we are trying to address that dynamic as well," she said.
She said that Cigna and other insurers are working to be able to track improvements in value and outcomes, but they're not there yet. "I don't think we have enough clinical detail," she said. "Oncology is very complex; very heterogeneous." With that said, Cigna conforms to NCCN guidelines in its clinical pathways and doesn't limit options among those recommended by NCCN, she said, but would like providers to look at value when selecting therapy.
Much of the discussion of value focuses solely on cost to the exclusion of the quality component of the value equation, said Randy Burkholder, vice president at the Pharmaceutical Research and Manufacturers of America. "I think our mission is to bring value to patients first and to the system overall," he said. "I think we have structures around value-based payment that are aligned around that."
Mr Burkholder claimed that the system is delivering value in the form of better treatments and outcomes, and that financial hardship is a function of more than just cancer drug treatment costs, as hospital costs, physician costs, and nonmedical transportation costs drive about 80% of the total cost of cancer care.
Pharmaceutical companies deserve to profit from breakthrough medications that offer value, said Lee Newcomer, MD, formerly chief medical officer at UnitedHealth Group, but he bemoans the lack of a "free market" when it comes to pricing. Pharma is using incentives built into the system, so a shift to help generate optimal value may require a change in the system, he argued.
In agreement was Ron Kline, MD, from the Centers for Medicare & Medicaid Services Center for Medicare & Medicaid Innovation (CMMI), who pointed out large differences in pricing for drugs in the same class with approximately the same effectiveness for the same form of cancer. A free market system wouldn't tolerate such price discrepancies.
Mr Burkholder countered that the market in cancer differs from that in many other diseases in that patients can respond to one treatment but then develop resistance and then require other therapies in the same class for subsequent lines of treatment. He added that strong clinical pathways and utilization management tools developed by institutions and payers have generated cost savings.
Has OCM Driven Value Discussions?
The Oncology Care Model (OCM) developed by CMMI encourages optimal treatment for patients at a high value, said Dr Kline, adding that value may be different between individual patients. "We don't tell physicians how to practice medicine," he said. "You decide as a physician what is best for your patient."
He believes that OCM has driven value discussions. "The pharmaceutical reps used to come in and buy us lunch, and now they come in and tell us why their drug has a higher value than their competitor," Dr Kline said. Cost factors, however, often aren't apparent to oncologists treating the patients in front of them, he admitted.
Dr Goodman asked how providers can make better value decisions without access to cost-effectiveness data and without the expertise on the business side of caring for patients. "This does not sound like an optimal operating system," he said.
The Hawthorne effect (ie, a change in behavior in response to awareness of being observed) is real, said Michael Neuss, MD, chief medical officer, Vanderbilt-Ingram Cancer Center, Nashville, TN. Physicians who are shown dollar amounts attached to their prescribing in relation to their peers will adjust their prescribing, he said. Physicians want such feedback, said Dr Mirda. "It is very clear that those data are valuable," he said. "We need more immediate data, but on the other hand, we also have to be able to take care of that patient and not have it driven completely by cost."
One of the underappreciated parts about the OCM is that OCM practices receive a quarterly detailing of their utilization of services and drugs and how it compares with other OCM practices and non-OCM practices, said Mr Burkholder. The secretary of Health & Human Services has the authority to apply the OCM at a national level, he said, depending on the demonstration project's success at achieving quality.
Lessons learned from OCM would be diffused more rapidly into practice by incorporating the data into electronic health records (EHRs) in the form of decision support tools, Dr Newcomer believes. When asked by Dr Goodman whether the data must be available in a timely fashion to support real-time decision-making, Dr Newcomer said that providers "don't need real-time data to make that happen at the immediate point. It informs what you build in decision support."
Dr Neuss said that measurements need to be incorporated into EHRs "and into care at the time we're delivering care." No EHR vendor has yet integrated American Society of Clinical Oncology or other measures into its base system, he said.
Some Data Already in Public Domain
Much data are already available in the public domain to drive value-based decisions, argued Dr Sagar. She cited a recently published cost comparison of pamidronate, zoledronic acid, and denosumab at their approved dosing schedules in which the price differential between the lowest-cost regimen and the highest-cost regimen for 1 year of treatment exceeded $25,000. "We should be able to look at it and take advantage of that information," she said. Cigna is exploring ways to use data such as these without dictating choice to the physician, she said, requesting that NCCN release categories of preference when recommending therapies in its guidelines. These data should also be available to patients.
"Part of our commitment to better value in cancer care is exactly that: getting the right information into the hands of clinicians and patients at the point of decision-making," said Mr Burkholder. "You do need to make sure there's a certain level of rigor to the data, whether it's from a clinical trial or from real-world experience, to know that it is adequate for the decisions that you are making. One of the basic things we can do is put better tools for that decision support into the hands of patients and clinicians so that they can act on best available evidence to make the decision that's right for that individual patient."
When Dr Goodman asked whether those tools should include comparative pricing information, Mr Burkholder answered that patients should know their expected out-of-pocket costs when discussing therapeutic options with their physicians.
Sometimes, physicians need to rely on data "that's just good enough," said Dr Newcomer, recognizing the difference between real-world data and the data that the FDA demand for registration. As long as the methods to derive cost comparisons are transparent, the data, even if not perfect, should be made available. "Don't kill it with regulations and make it so perfect that it never sees the light of day," he said.
Whereas taking care of the patient is always the first priority, financial incentives must be aligned, said Dr Kline. "One of the ways you bring value into the system is take a physician practicing and say, 'Look, if you can provide high value care, were going to give you a performance bonus.' That's the way the rest of the economy works," he said.
When challenged that CMMI won't allow a higher cost for better patient care, Dr Kline responded that CMMI does take into account national medical expenditure trends in developing the OCM.