The escalating costs of cancer care are now referred to as “financial toxicity.” At the recent 2017 Annual Meeting of the Multinational Association of Supportive Care in Cancer, Ronan Kelly, MD, Johns Hopkins Medicine International, The Sidney Kimmel Cancer Center, Baltimore, MD, spoke about financial toxicity, the need for value-based care to address it, and what oncologists and healthcare providers can do to reduce costs of cancer care.
“The topic of utilizing value-based assessments in medical oncology is exploding in the US. This is not just about drugs but about the value of all the things we do in cancer care,” Dr Kelly told listeners. “Some of these costs are under the oncologist’s control, including unnecessary testing and unnecessary imaging, inappropriate end-of-life care, and cutting back on emergency room admissions.”
No one doubts that the costs of cancer care are escalating out of control. By 2022, the number of cancer survivors will increase by 30%, and the incidence of cancer is projected to increase by 45% in 2030. Costs of cancer increased from $72 billion in 2004 to $125 billion in 2010 and are expected to reach $173 billion by 2020.
The costs of drugs to treat cancer have risen exponentially. “Drugs used to treat cancer outpace the gross domestic product and the [other] costs of cancer care, and we have no idea what the costs of immunotherapy and immunotherapy combinations will be,” he continued.
“Unfortunately, the costs of cancer drugs are not related to efficacy, nor is current drug pricing rational,” he noted. “In the US, patients have to bear much of the cost of drugs, and financial toxicity is becoming the norm. As the impact of co-pays is increasing, many patients can’t afford to take their medications as prescribed.”
Because of high out-of-pocket costs for patients, one study found that 20% of patients took less drug than prescribed, 24% didn’t take the drug at all, and 19% took half the amount prescribed (Oncologist. 2013;18:381-390).
The European Society for Medical Oncology (Magnitude of Clinical Benefit Scale), the American Society of Clinical Oncology (ASCO; Value-Based Algorithm), the National Comprehensive Cancer Network (Introducing Cost into Guidelines), and other organizations have developed frameworks for determining value of treatments. Examples of these can be accessed online at the websites of these organizations.
“Not all of them include cost and cost-effectiveness,” Dr Kelly said.
Treatment pathways are being developed to address rising treatment costs, but there are limited data on whether pathways are effective. These pathways attempt to compare regimens and factor in efficacy, side effect profile, and cost, coming up with preferred regimens. Insurance companies are interested in the cost benefit of pathways. Some studies suggest that at the end of life, pathways result in less chemotherapy, fewer hospitalizations, and greater use of hospice. But the benefits of pathways need to be proven in large randomized trials.
Role of Healthcare Professionals
Inappropriate care at end of life is responsible for much of the increased cost of healthcare in the United States.
“Studies show that doctors can do more to improve value of care at end of life. Use of hospice needs to be increased, while hospitalization and admissions to the intensive care unit should be decreased,” he stated. “Twenty-five percent of the costs of Medicare are for the last year of life, and 40% for the last month of life, amounting to 10% of the total Medicare bill. This is not easy to figure out,” Dr Kelly told listeners.
Costs need to be discussed with patients. A study by Dr Kelly and colleagues found that patients feel it is extremely important to get information on costs of care, yet most oncologists do not do this (J Oncol Pract. 2015;11:308-312). The authors of that article said that clinicians need additional training to discuss costs with their patients.
Dr Kelly advised oncologists to talk with their patients about costs of care. “When it is done appropriately, patients are not upset about discussing costs. Timing is important. Don’t do it at the beginning of treatment or at disease progression,” he noted.
Inappropriate use of imaging is a contributing factor to escalating costs. “There has been an exploding use of imaging. Radiologist-owned Medicare PET scan usage increased 259% between 2002 and 2007, whereas oncology private practice nonradiologist-owned or -leased scans grew by 737%, a shocking statistic,” he said.
The Choosing Wisely campaign for oncology recommends various strategies for cutting costs based on reducing inappropriate interventions that include imaging (www.Choosingwisely.org).
“Treatment choices are under our control,” he told the audience. “We don’t always need to use the most expensive drugs first.” Other cost-cutting measures include not using expensive supportive care, such as pegylated filgrastim, and using 1 unit of blood instead of 2 for anemia.
“We need better information on real patterns of care. This is under our control, and this is where efforts at cost containment are going in the US,” he said.
Institute of Medicine Initiative
The Institute of Medicine issued a mandate in 2013 to focus on value-based cancer care. Approaches include integrating electronic health records into computer-based systems. New payment models are being developed to incentivize doctors to use value-based approaches to cancer care.
The Quality Oncology Practice Initiative (QOPI) includes modules on symptom management for breast, colon, and lung cancer, and these include patients’ emotional well-being as a quality metric. QOPI certification for hospitals is based on a score derived from electronic health records to determine if the hospital is delivering quality care.
CancerLinQ is a big data initiative from ASCO that extracts data from the cloud and allows doctors to compare their practices with those of their peers. Data for millions of patients are now in the cloud.
“For example, big data can be used to look at practice patterns for a rare disease like male breast cancer,” he said. As of 2019, under the MACRA Medicare payment reform program, payments for doctors will morph from fee-for-service to value-based care. “There will be no reward for doing ‘more,’” he said.
“Value-based care is where we are going. Payment will be based on high quality and efficacy, changing the way we practice medicine,” Dr Kelly said. “A quality payment program started this year. There is widespread confusion about this, and we are still on a learning curve, but this is the future.”
“Right now, most oncology spending does not go to the oncology practice. Only 10% goes to practice, while 90% goes for drugs, lab tests, imaging, surgery, ER visits, and hospitalizations,” Dr Kelly said. “The future will be patient-centered oncology practice, and physicians will be placed at the center of the value equation.”