Quality of Cancer Care Falling With Doc Shortages and Rising Costs

Roxanne Nelson

March 11, 2011

March 11, 2011 — A shortage of oncologists and the rising costs of chemotherapy agents, radiation therapy, and imaging tests are making the delivery of quality cancer care increasingly difficult.

In addition, according to a new review by researchers from RTI Health Solutions and Eli Lilly, published in the March 1 issue of Cancer, the definition of quality cancer care differs among patients and physicians.

It is difficult to achieve high-quality cancer care without an understanding of the perceptions of quality, explained lead author Ann Colosia, PhD, a senior associate in market access and outcomes strategy at RTI Health Solutions in Research Triangle Park, North Carolina.

"With all of the changes in cancer care — more patients and fewer oncologists, higher cost of care, need for reducing costs — we undertook a literature review with the goal of understanding what has been learned about stakeholder perspectives that were collected through surveys and interviews," Dr. Colosia told Medscape Medical News. "The idea was to present the key results of these studies in a coherent summary to oncologists, nurses, patient communities, and payers as part of the efforts to encourage conversation among these groups."

A number of converging factors currently affect quality of care, and will continue to do so in the future. The current efforts at healthcare reform must reflect these different needs to maintain and improve quality while controlling costs.

Dr. Colosia and colleagues conducted a literature review to gain a better understanding of the perceptions that patients, physicians, and managed care professionals have about quality cancer care. They identified 25 sources that described interviews or surveys with patients, providers, or professionals in managed-care settings.

Patient and Provider Differences

Studies that evaluated patient perceptions of care showed that patients reported receiving high-quality cancer care when they were given information about their health and treatment, were able to participate in decision making, trusted their practitioners, and believed that their care was well coordinated.

Patients were concerned about their interactions with their healthcare practitioners, and were more likely to notice a lack of positive interactions than quality interactions.

Healthcare providers, in contrast, appeared to perceive quality cancer care as making decisions on the basis of the risks and benefits of specific chemotherapy regimens and the health status of the patient, rather than costs. Research showed that they objected to having to spend a substantial amount of time interacting with payers instead of caring for their patients.

"There are no easy answers for reconciling the physicians' and patients' views of what represents quality cancer care," said Dr. Colosia. "These groups face different pressures."

"Certainly the physicians and nurses caring for oncology patients are concerned about the patient and undergo repeated training to stay current on the technical aspects of treating the disease," she explained. "Providers also try to do their best to foster patients' perceptions of quality in the way they treat them, and it should encourage [them] to know how much patients' perceptions depend on nontechnical aspects of their care."

More Patients, Fewer Oncologists

"The quality of cancer care is under pressure in part because of the rising number of cancer patients in the United States," said Dr. Colosia. But in addition to more patients, there is also a looming shortage of oncologists.

The number of cancer patients is expected to grow by 55% by the year 2020, which will significantly outpace the availability of oncologists (J Clin Oncol. 2008;26:3242-3247). This will lead to an estimated shortage of between 2550 to 4080 oncologists in the United States by 2020.

One of the challenges will be to train more geriatric oncologists; the "aging" of America alone is projected to increase the total number of annual cancer cases by 45% (from 1.6 million to 2.3 million) by 2030.

The review authors note that the number of nurse practitioners and physician assistants will likely increase to compensate for the shortage of physicians. "Education programs must be developed to address cancer-specific procedures, clinical situations, and reimbursement issues as the roles of these professionals in cancer care increase," they write.

Care is Costly

As previously reported by Medicare Medical News, the cost of cancer care in the United States, even among those with insurance, can put patients at risk for huge medical debts, delays in treatment, and bankruptcy.

"Cancer patients too often find out that their insurance doesn't protect them when they need care the most," John R. Seffrin, PhD, national chief executive officer of the American Cancer Society, commented recently.

Spending on cancer drugs has risen faster than spending in many other area of healthcare in the United States. A recent health policy report published in the New England Journal of Medicine (2009 360:626-633) noted that health economists are concerned that, at least in some cases, the cost of oncology drugs appear to be rising faster than the health benefits associated with them.

Advances in diagnostic and surgical techniques and pharmaceutical innovations have all contributed to rising cancer care costs. "But there's no question that the key driver is the cost of the drugs," said the author of that report, Peter B. Bach, MD, associate attending physician at Memorial Sloan-Kettering Cancer Center in New York City.

"When drugs cost thousands of dollars a month, then treatment can get very expensive," he told Medscape Medical News when his report was published.

In their review, Dr. Colosia and colleagues note that new and innovative cancer drugs can cost payers an additional $10,000 to $20,000 or more for just the initial phase of treatment. Even higher costs will be incurred if the drug is administered over the long term.

Payers generally require authorization before these drugs are prescribed to ensure that they are used in accordance with FDA guidelines or compendia recommendations. But the costs of chemotherapeutic agents and supportive drugs increase indirectly, the authors point out, when considerable time is required to fill out extensive authorization forms.

Requiring authorization reduces the time that providers, especially nurses, can spend with patients. This can negatively affect providers' perceptions of the quality of care they administer, note the authors.

"There are some quite costly therapies for cancer patients, and through continued research we will learn which patients benefit the most from these therapies," said Dr. Colosia.

Studies have shown that payers must control the costs of cancer care, but payers do not want an adversarial relationship with providers and patients. Methods of managing cancer more efficiently involve working with providers to develop assessment and decision-assist tools.

Innovations From ASCO

Dr. Colosia pointed out that the American Society of Clinical Oncologists (ASCO) is providing leadership to address quality cancer care issues.

"ASCO has established 2 committees — the Quality of Care Committee and the Cost of Cancer Care Task Force — to facilitate improvements in the quality of cancer care and provide payers with information that will inform reimbursement policies," she said.

The Quality of Care Committee is concerned with establishing and documenting best practices, such as developing cancer treatment plans and overseeing the Electronic Health Records Group, explained Dr. Colosia. "The Cost of Cancer Care Task Force encourages physicians, social workers, and medical facility financial experts to discuss the cost of cancer care with their patients."

Eli Lilly and Company provided funding in support of this research. Coauthors Gerhardt Pohl, PhD, Esther Liu, PharmD, and Gerson Peltz, MD, MPH, are employed by Eli Lilly and Company and own stock in the company. Dr. Colosia and coauthors Kati Copley-Merriman, MS, Shahnaz Khan, MPH, and James A. Kaye, MD, DrPH, are employed by RTI Health Solutions, a business unit of RTI International.

Cancer. 2011;117: 884-896. Abstract

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