Oncologists Can Cut Costs While Maintaining Quality of Care

Roxanne Nelson

February 14, 2014

The alarmingly high increases in the cost of cancer care can be reined in. However, it will require that the oncology community take responsibility for practice patterns, according to 2 experts.

In a report published online in the Lancet Oncology, Thomas Smith, MD, and Ronan Kelly, MD, both from the Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins Medical Institutions, Baltimore, identify 3 major sources of high cancer costs that can be reduced with the least amount of harm.

They also look at innovative healthcare models that preserve quality while reducing costs, such as medical homes, US Oncology's Clinical Pathways, and the Choosing Wisely campaign from the American Society of Clinical Oncology (ASCO).

For oncologists, changing practice patterns should be a priority when trying to make care more affordable, said Dr. Smith. "Oncologists should be responsible for the part that we can control."

"Thankfully, patients are surviving longer with their cancers, but we can't keep going in the current direction without bankrupting the system," he told Medscape Medical News. "We will eventually get to the point where we think of ourselves as being 'all in this together,' but we're not there yet."

Drs. Smith and Kelly point out that although professional societies, such as ASCO, are beginning to guide oncologists on reducing costs, actual changes in clinical practice are happening slowly.

Less Expensive, Better Quality

What is impressive about this report is that it presents evidence indicating that more compassionate and less expensive courses of action actually produce better outcomes, said Howard Brody, MD, PhD, director of the Institute for the Medical Humanities and a professor of family medicine at the University of Texas Medical Branch in Galveston.

"Or at least they do not limit survival chances," explained Dr. Brody, who was approached by Medscape Medical News for independent comment.

"The entire goal of Choosing Wisely and related efforts is not simply to cut costs, but more importantly to improve the quality of care for patients. It's heartening to know how often these 2 desirable ends can be accomplished together," he noted.

The "next important point to stress is the absolute need to incorporate patients' perspectives into the policy approaches," he said. Dr. Brody is currently involved in a pilot effort to engage community groups in discussing the ethical issues related to comparative-effectiveness research.

"One point mentioned by the 2 community groups we have convened is the need for patients to grasp any thread of hope, no matter how slim, when faced with a devastating disease like cancer," Dr. Brody told Medscape Medical News. "One can deal with this and still provide patients and families with the tools needed to make rational choices that will ultimately provide for better quality of life, but it takes time, effort, and sensitivity."

Costs Will Not Restrain Themselves

Even in high-income countries, the cost of cancer care is becoming unsustainable and a drastic shift in cancer policy is needed to rein in current costs, according to a 2011 report (Lancet Oncol. 2011;12:933-980). In the intervening years, it has become evident that "costs will not restrain themselves, and that direct and often uncomfortable actions are required," Drs. Smith and Kelly write.

They point out that all cancer costs are an issue; pharmaceuticals account for 24% of the total cost, hospital care for 54%, and physicians for 22%. However, they identify 3 key categories of rising costs in cancer care.

The first category deals with the increasing number of cancer cases in an ageing population, more and longer survival, the higher expectations of patients, and the rising cost of treatment.

The second category deals with imaging costs, which have risen 5.1% to 10.3% per year since 1996. "Medical imaging costs have increased without attendant changes in mortality from metastatic disease," note Drs. Smith and Kelly.

The third category deals with drug costs, which have increased 10-fold in the past decade, regardless of whether or not they are targeted or the degree of benefit they provide.

Drs. Smith and Kelly focus on safe and ethical cost-cutting solutions for patients with metastatic cancer, not on new surgical or radiation treatments, clinical trials, curative care, or pediatric care, because those constitute less than 5% of total costs.

The Big 3 Recommendations

End-of-life care can be improved with better decision-making and planning, which could save a significant amount of money. It "has become more intensive, not less, in the past 10 years," the authors note.

In fact, 60% of Medicare beneficiaries are admitted to a hospital in the last month of life, and a quarter of them end up in intensive care units. Thirty percent of these patients die in the hospital, and only 54% ever use a hospice, with a median length of stay of 8 days, they report.

But, in addition to saving $2700 to $6500 per person, hospice care improves symptoms and reduces caregiver distress.

Drs. Smith and Kelly recommend the integration of palliative care earlier, with transition to a hospice when appropriate, and recommend that patients have earlier discussions with their oncologists about chemotherapy use at the end of life. This is also the recommendation of ASCO, which issued a provisional opinion in 2012 to extend early palliative care to all patients with metastatic cancer, although the evidence so far shows a survival benefit only in patients with metastatic non-small cell lung cancer.

Oncologists can also curtail expensive and often unneeded medical imaging.

One Choosing Wisely recommendation is to "avoid using positron emission tomography...as part of routine follow-up care to monitor for cancer recurrence...unless there is high-level evidence that such imaging will change the outcome," Drs. Smith and Kelly note.

Although this "administrative solution" is clear, as outlined in the ASCO guidelines, the clinical solution is more nuanced, they write. For example, there are patients and physicians who are convinced that only a PET scan will show lung cancer recurrence in the liver, which could then be treated with curative intent. "Clinicians explaining the truth to patients about curability will allow most patients to choose wisely," the authors explain.

Finally, they suggest that reducing the price of new cancer drugs could help lower the economic burden. One key ASCO recommendation is that oncologists discuss the issue of cost with patients, but most do not know the cost themselves, and many do not feel adequately trained to have this type of discussion.

For drugs that cost tens of thousands of dollars, there is "an unbalanced relationship between cost and benefit," said Dr. Smith. "We need to determine appropriate prices for drugs and inform patients about the cost of their care."

One approach is to create an association between the drug price and the amount of time that life is prolonged. For example, a drug that prolongs life more than 6 months can cost $50,000 to $60,000 per year, whereas a minimally effective drug, with a survival benefit of less than 2 months, can cost less than $30,000 per year.

The US Institute of Medicine task force noted that a system is needed that is "rational and not rationed," the authors point out. "These thresholds are a start to prevent continued medical profiteering without rationing."

Models That Work

Currently, several innovative models are being used to reduce costs without sacrificing quality. The model used at Veterans Administration Medical Centers results in outcomes identical to those achieved for many common cancers in fee-for-service cancer care practices.

Another model is the medical home, which provides a team approach to full care for a set fee. These practices provide comprehensive care, share information with all providers, adhere to set performance measures, and charge one fee that covers all services.

One oncology practice that adopted this model achieved a 68% reduction in emergency department visits and a 51% reduction in hospital admissions, and saved $1 million per physician per year, the authors report.

US Oncology, the largest private practice oncology group operating in the United States, has developed a system of clinical pathways. They have partnered with insurers to use preferred treatment pathways for adjuvant and metastatic regimens in breast, lung, and colorectal cancers. Another group that has developed clinical pathways, Cardinal Health, has also shown that they can reduce cancer care costs.

"These pathways specify the type of treatment that can be given, so it is not up to the doctor to choose what he or she thinks its best," explained Dr. Smith. "It has been predetermined by a group that has studied all of the data and made the decisions based on the most evidence."

The pathways permit only specific drugs (generally generics), limit the lines of chemotherapy, involve social workers and others to address advanced directives, and increase the use of hospices. For outcomes, including survival, pathway treatments compare favorably with nonpathway treatments. With pathways, about 83% of patients have an advance directive, and total direct care cost is reduced by 33% to 53%.

"This example is an exciting model for cost control that could actually improve quality of care and reduce costs, but more experience is needed to see whether its success can be transferred to other treatment settings," Drs. Smith and Kelly conclude.

Both authors are supported by a US National Cancer Institute core grant to the Sidney Kimmel Comprehensive Cancer Center. Dr. Kelly reports serving on a data monitoring committee for Novartis.

Lancet Oncol. Published online February 14, 2014. Abstract


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