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NCCN Panel Addresses Value-Based Care in Oncology

April 2015, Vol 6, No 3

Hollywood, FL—Value-based decision-making at the bedside can be fraught with obstacles, with no clear agreement on what constitutes value, and for whom. In addition, the myriad insurance plans preclude uniform treatment strategies, despite clinical pathways and guidelines intended to reduce variation in care. Finally, value is becoming more difficult to achieve in oncology as each benefit becomes more expensive, with the cost of new therapies outpacing inflation.

These were some of the themes raised by a panel of oncology experts who discussed value-based cancer care at the bedside during the 2015 National Comprehensive Cancer Network (NCCN) conference.

Pathways Can Improve Quality of Care

Guidelines and pathways are a shared decision support tool that provides an opportunity to document how clinical decisions are made, especially when a decision falls outside of a guideline, said Stephen B. Edge, MD, Director, Baptist Center for Cancer Care, Memphis, TN.

Most cancer treatments given at the bedside are in concordance with guidelines, but Peter B. Bach, MD, Director, Center for Health Policy and Outcomes, Memorial Sloan Kettering Cancer Center, New York, contends that many guidelines have been created to merely reflect clinician behavior.

“There’s a sort of tautology that the entities and institutions that develop the guidelines are essentially codifying what they currently do,” said Dr Bach. “Although there may be high concordance, it’s not clear which direction this information is flowing.”

Guidelines may not be appropriate at the bedside, because they incorporate all potential alternatives, said Jennifer Malin, MD, PhD, Medical Director of Oncology, Anthem (previously WellPoint). The intent of clinical pathways in most situations is to assist the practicing clinician in selecting the most effective regimen among the choices for a particular patient.

“Another way to look at pathways is you’re enabling your physicians to deliver a smaller number of treatments, which should improve the quality of that delivery,” said James L. Mohler, MD, Chair, Department of Urology, Roswell Park Cancer Institute, Buffalo, NY, and Chair, NCCN Prostate Cancer Treatment Panel.

“Most of the pathways have some of the most expensive therapies on them, but you do see ranges in cost of therapy,” said Dr Malin. “If on average, as a community we move toward practicing value-based care, we will see not that we save dollars, but the cost of care won’t rise as rapidly.”

Pathways can be considered “a form of sophisticated formulary management conducted by payers or intermediaries that essentially tiers treatments as preferable or not. This is a logical response to large variations in the cost of therapies,” said Dr Bach. “To the extent that things are really interchangeable, it’s highly efficient to have pathways that incentivize doctors to use the cheaper of the available interchangeable regimens.”

There may be a transparency concern, however, when physicians are being incentivized to follow pathways, and patients don’t know about it.

Value for Whom?

According to Linda House, RN, BSN, MSM, President of the Cancer Support Community Global Headquarters, Washington, DC, despite being aware of guidelines and receiving information about their diagnosis and potential treatments, more than 50% of patients say that they are unprepared to make a treatment decision.

Although guidelines may list toxicities of the various treatment options, patients may weigh these toxicities ­differently from clinicians, making treatment decisions difficult. The disconnect that happens during the decision-making moment also pertains to the value of care received. “There’s a big disconnect between how patients define value and how health economists define value,” said Ms House.

“We have to define value, and we have to be honest about who we are looking for value for,” said Dr Edge.

The pressure that clinicians are under to maximize revenues implies that value-based decision-making may favor the payer or the institution over the patient.

The medical community does not “value the data that patients would need for these decisions the same way we value data we traditionally care about,” said Dr Bach, using the example of the recent approval of nivolumab (Opdivo) for the treatment of metastatic squamous non–small-cell lung cancer. Although quality of life was an end point in the clinical trial submitted to the FDA for the New Drug Application for nivolumab, only the gain in survival was mentioned in the company press release touting the approval, and the final data have not yet been published. Patients are being asked to make a treatment decision without these important data, Dr Bach said.

Patients can make reasonable choices if presented with the full level of information, according to Ms House. Physicians can be incentivized to provide such information to patients with a fee for quality-based care management that would include distress screening, treatment decision counseling, and overall care planning, she said.

Economics Impacts Care Quality

Because physicians are largely not equipped to speak about costs, costs rarely direct a shared decision about cancer treatment, said Dr Mohler. Instead, clinical practice may be influenced by the ownership of technology (ie, radiation machines) that needs to be paid for. “In the case of radiation doubling the cost of care for prostate cancer, the insurers all know that,” he said. “They have the data, yet they have been unwilling to go to case rates or restrain practice.” Patients are also known for wanting the newest technology, which is also the most expensive.

When asked how he copes with economics in the examination room, Dr Edge noted the difficulty in providing accurate information about out-of-pocket costs when there are 50 to 100 different insurance products.

Cancer drugs approved in 2015 cost at least $15,000 monthly, yet some patients cannot keep appointments or fill their prescriptions because of a $75 copay, said Dr Malin. “We are all implicitly making trade-offs and spending more on healthcare that isn’t often producing value,” she said. The plans under the Affordable Care Act also encourage trade-offs by varying the amount of out-of-pocket costs according to the monthly premium.

“High coinsurance, particularly for things like drugs for CML [chronic myeloid leukemia], are a byproduct of high unit prices for those drugs,” said Dr Bach. “We have population data showing that as coinsurance rises, people leave their Gleevec at the counter. This is one of the biggest disappointments that we can experience. We have maybe the biggest cancer breakthrough in our lifetime being left at the pharmacy counter because of economics.”

The 8% inflation-adjusted growth in the cost of cancer drugs “equates to a 100-fold increase in the monthly cost of cancer drugs since the dawn of the Medicare program in 1965,” said Dr Bach, without a corresponding 100-fold increase in value. “Each year we get a new cancer drug at a cost of a year of life gained, that drug goes up by $8500,” he said. “This is a classic version of spending with diminishing returns.”

With health insurance premiums costing approximately 50% of the average person’s take-home pay, there is no room for premiums to increase, suggested Dr Malin; and this makes future choices even more difficult. “Can we encourage value-conscious care in a way that preserves the clinician’s ability to work with the patient and do shared decision-making?” Dr Malin asked.

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