Lidia Schapira, MD; Beverly Moy, MD, MPH


July 20, 2012

Editor's Note:
At the American Society of Clinical Oncology (ASCO®) 2012 meeting, Beverly Moy, MD, MPH, chaired the educational session "Ethical Challenges of Health Care Reform for Oncology Providers: A Debate," in which a community oncologist, research oncologist, academic oncologist, and representative of an insurance provider debated the challenges of providing quality care to an increasing number of patients in the face of rising costs and increased pressure to contain expenditures. Lidia Schapira, MD, caught up with Dr. Moy after the debate to ask her about key questions raised by the discussion.

No Time Left to Waste

Lidia Schapira, MD: Were there comments from today's audience or your fellow presenters that you found particularly compelling?

Beverly Moy, MD, MPH: The audience was extremely engaged. There isn't anybody in the oncology community who isn't affected by healthcare reform and the many cost issues and ethical issues that arise from it. I was especially happy that Lee Newcomer from UnitedHealth Group agreed to be on the panel because he offers a unique perspective -- that of the payer and practicing medical oncologist. He understands the frustrations and ethical dilemmas that many oncologists feel.

Dr. Schapira: One thing that I heard him say very clearly is that we have run out of time. Do you feel the same way?

Dr. Beverly Moy

Dr. Moy: We certainly should feel a sense of urgency, and we should have been feeling a sense of urgency long before the Affordable Care Act (ACA) was passed. The problem exists and it is up to us to address it. If anything, the ACA has brought more attention to this issue. The law itself actually doesn't do very much about cost control, but it catalyzes us to start thinking about it. Lee Newcomer is absolutely right that the situation is one of incredible urgency.

Healthcare Reform: 1 Physician at a Time

Dr. Schapira: What should we be thinking about, not so much on a policy level, but as individuals and practicing oncologists?

Dr. Moy: It is really important that the oncology community very seriously think about how we practice medicine. ASCO® is already leading the charge by participating in the Choosing Wisely® campaign of the American Board of Internal Medicine and by issuing a recommendation for the top 5 ways that oncologists can cut costs.[1] That is a good first step. Most oncologists would probably feel that the 5 practices that they identified are relatively low-hanging fruit, because they are expensive and there is little to no evidence to indicate that they are helpful.

We have to think about what medicine means in this new model that involves bundled payments and Accountable Care Organizations. Before I left for the ASCO® meeting, I saw a study in the American Journal of Managed Care that found that in clinics using value-based purchasing or that involved bundling payments, doctors had to see more patients in shorter periods of time.[2] That is something that we are going to have to prepare for. There are going to be unsettling changes around having to deliver high-quality care in a more efficient and more low-cost manner.

Will Referral to Palliative Care Fade Away?

Dr. Schapira: One question about this issue of the bundled payments, especially if you think about patients who are critically ill: Will there be competition between oncologists and palliative care physicians for patients? In other words, if there is a global payment for care, will it actually discourage referral to palliative care?

Dr. Moy: I don't think so. You are basically asking whether care will be less multidisciplinary because of the bundled payment, and because people have to share in the bundle. Many studies have looked at palliative care in terms of cost/benefit, including the lung cancer study that Jeff Peppercorn mentioned.[3] Treatment can be cheaper if you get palliative care involved. At the end of life, there are fewer stays in the intensive care unit, and stays in the ICU can be incredibly expensive. We will find that using palliative care will be helpful, but we will probably have to be more discriminating about getting unnecessary consultations. Palliative care is an example of a service that will do well because of healthcare reform.

Dr. Schapira: How can we provide doctors with incentives to make sure that this system, which you suggest is more guideline driven and more deliberative, is actually implemented?

Dr. Moy: There are no easy answers to that question. Initial attempts have been made, at our institution and others, to tie in quality metrics as incentives for physicians. There are models outside of cancer; for instance, in orthopedic surgery in certain hospitals, physicians receive incentives for reaching certain metrics. Deciding which metrics are appropriate is a problem, but metrics are increasingly being used to incentivize doctors to provide more evidence-based, efficient care.

"Sorry, but the Treatment You Want Isn't Worth It"

Dr. Schapira: In the United States, do you think that patients will accept the doctor saying, "There is this cancer drug that may extend your life by a few weeks, but I don't think it's worth it in your case"? Do you think that we will get to a point where a doctor will feel comfortable saying that and a patient will feel comfortable hearing that?

Dr. Moy: You are asking the right question. That is the major ethical dilemma. We can talk about skyrocketing healthcare costs and how urgently this issue needs to be fixed, but when you are in a room with an individual patient, there is a conflict. The conflict is, what is my duty? Is it to society, or is it to this patient sitting in front of me? There is certainly no easy answer.

Dr. Schapira: It seems to me that there may be 2 tracks one would need to take. One is to engage the public in debate and raise awareness; the other is to attempt an attitudinal change among oncologists. Can you talk about how ASCO® is approaching this issue?

Dr. Moy: ASCO® has been very proactive in making their guidelines more user-friendly and publishing policy statements about how to cut costs and what the evidence says. So, ASCO® is doing a very nice job of providing oncologists with the evidence to say, "I will not be scanning you. Here's why." That is very important, for oncologists to be able to say that ASCO®, as a major medical society, has looked at the guidelines, looked at all the evidence, and issued this recommendation.

But there has to be a shift in public perception, because Americans are used to a level of healthcare service that, quite frankly, is unsustainable. We, as doctors, are caught in the crossfire. We are with the patient who has certain expectations and we are the stewards of healthcare. So, it is important that we are able to provide resources for the doctors to have this conversation more easily, but there really is going to need to be a shift in public perception and expectations.

Going After More Medicaid Reimbursement

Dr. Schapira: It is your passion to think about disparities and how to reduce them, and one of the obvious ways is to improve access to healthcare. Hopefully, the ACA will do that. What other initiatives or pilot programs would you like to see implemented to chip away at the issue of disparities in healthcare?

Dr. Moy: The point was made this morning that cancer disparities existed before the ACA was passed, and they will exist even if the law is upheld in the Supreme Court. Although it is a big step forward, expanding Medicaid access to all these millions of Americans is not the remedy.

What are we really offering patients when we offer them access to Medicaid? There will be ongoing cuts to Medicaid and Medicare, so much so that practices will not be able to take care of these patients. Where are they going to get healthcare? One of the audience members made a good point: The law gives patients access to health insurance; it doesn't give them access to healthcare.

One obvious way to remedy the situation is to fix reimbursement so that doctors can take care of all of these patients and not have to turn away Medicaid or Medicare patients, which is increasingly happening across the country. We need to be able to do the best we can to increase access to care for all vulnerable populations in the United States.

Adding Patients to the Healthcare Pie Chart

Dr. Schapira: What projects are already under way to improve access?

Dr. Moy: The Patient Navigation Research Program, which is funded by the National Cancer Institute, seeks to reduce cancer health disparities by helping patients gain access to quality cancer care on an efficient basis. The ACA extended patient navigation from a previous law that was going to expire. But navigation is not the only intervention that will help patient disparities. There is a big emphasis in the ACA on comparative effectiveness research and shared decision-making research. There are some really great things in the law about disparities research. The Office of Minority Health has been elevated to Institute status, and there is also the Patient-Centered Outcomes Research Institute, so there are lots of things in the law that, if they receive funding, would be fantastic.

Dr. Schapira: What would you recommend be done, on the basis of what we already know, to level the issue of access and reduce disparities? What have we learned that we could begin to roll out?

Dr. Moy: That is a really tough question. We know very little. Disparities research has focused on identifying disparities but not necessarily on addressing them. There are very few good studies that look at successful interventions to reduce disparities.

Dr. Schapira: Navigation would be one, and it could be interpreted broadly. There is no one job description of a navigator; it could be both for improved access to screening or to comply with treatment visits or follow-up. Do you have any other thoughts about strategies that work?

Can Extending Access Improve Care?

Dr. Moy: One reason that we don't know very much about disparities in racial and ethnic issues is that data collection has been extremely poor, even for patient-centered clinical trials. There is some minority enrollment in trials, and the Cooperative Groups are figuring out how to best collect data on these patients because we already have all their outcomes. It is in the trial data.

The ACA mandates data collection for all agencies that take payer patients. That will include race, gender, ethnicity, and disability status. That is going to be very helpful for disparity research, but for comparative effectiveness research, one thing that could be done is to look at the data we already have and try to answer questions. For example, JAMA published a paper that concluded that bevacizumab slightly improves overall survival of patients with metastatic lung cancer.[4] But investigators looked back at patients over age 65 in this database to see how bevacizumab did in the elderly, and it didn't appear to do very well. It's not a definitive study, but it is an important, real-life study.

Dr. Schapira: Would you pose an age limit on the use of bevacizumab in patients with metastatic lung cancer?

Dr. Moy: It's something that needs to be considered. That is the kind of question that can be answered easily by disparities research. We have existing data and we haven't asked the right questions.

Doctors as Advocates

Dr. Schapira: Do you think there is enough interest, good will, and desire to push these reforms forward? Do you think it is time?

Dr. Moy: I hope so. It is great that at the ASCO® annual meeting a good amount of attention focused on cost of cancer care. Oncologists aren't wired necessarily to think about advocacy or legislation or the law or policy because we are doctors. It hasn't been part of our job description. That needs to change because we need to advocate for ourselves and our patients. Although it is very exciting to hear about the latest multitargeted therapy, it is equally important to understand the implications behind these issues that will affect us greatly.


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