What Is Value to the Cancer Patient, Oncologist, and Payer?

Roxanne Nelson, BSN, RN


July 13, 2015

Editor's Note:
Last year, the American Society of Clinical Oncology (ASCO) launched an initiative to define value in cancer care. Recently, ASCO took that initiative a step farther by publishing a proposed framework[1] for assessing value in cancer care, and invited the public to provide feedback over a 2-month period.

But to measure value, it is important to understand what "value" means—and it means quite different things to different people. How is value defined by the patient, provider, and payer? At a session held at ASCO's annual meeting,[2] panelists representing these key stakeholders discussed their perspectives on value in cancer care.

High Price May Not Mean High Value

Warren Buffet, the famed business magnate and philanthropist, has been quoted as saying, "Price is what you pay. Value is what you get."

Price and value are not the same, and it was that premise that drove ASCO to focus on value rather than on cost alone. The escalating price tag of healthcare in the United States, including cancer care, is receiving increased scrutiny from policymakers, the media, and the public at large, but there is also widespread recognition that high prices do not necessarily translate into high-quality care or improved outcomes, according to Lowell E. Schnipper, MD, chair of ASCO's Value in Cancer Care Task Force and chief of hematology/oncology at Beth Israel Deaconess Medical Center in Boston.

"The cost of cancer care is not just a national issue, but every one of our patients, except for those who are particularly well off, are experiencing it," said Dr Schnipper, who presented an overview of the ASCO initiative on value in cancer care. "This concern about cost, and cost reduction has begun to penetrate physician practice, whether out in the community or in academia."

The purpose of the ASCO Value Framework[1] is to define value in cancer care in order to help physicians and their patients make the best decisions for potential cancer treatment options. "This is part of ASCO's long-standing mission to improve access to high-quality, high-value care for every patient with cancer," said Dr Schnipper. "And our task force has focused not just on the problem, but the doctor/patient interface. The goal is to optimize the use of a tool that can customize information for each patient."

More specifically, the goal is for the patient and physician to enter into a discussion and for the patient to receive information that he or she understands. "Patients will walk away feeling that they are receiving a high-value interaction—both in terms of the communication and the treatment they will be receiving," he pointed out.

Although it is obvious that clinical benefit, toxicity, and cost are important factors, what isn't obvious is how you develop metrics to grade and quantify them.

ASCO's Value in Cancer Care Task Force has defined "value" as the combination of three factors for a cancer treatment regimen: clinical benefit, toxicity, and cost. These are the factors that matter most to patients, according to ASCO.[3] Therapies that have the highest clinical benefit, the least toxicity (and are thus the most tolerable), and that are affordable would represent higher value.

Although it is obvious that clinical benefit, toxicity, and cost are important factors, "what isn't obvious is how you develop metrics to grade and quantify them," explained Dr Schnipper during his talk. "The difficult part is how you develop metrics to distinguish one from another. We need valid metrics to distinguish the magnitude of difference for each variable."

Another issue is that cancer patients, or at least some subgroups, may place a higher value on different variables. As an example, Dr Schnipper pointed to a study from the Cancer Support Community that was presented this year at the Association for Value-Based Cancer Care annual meeting, which asked patients with metastatic breast cancer to define value relative to healthcare.[4] The authors of the study concluded that "value is multivalent."

"Many of the patients valued healthcare provider relationships very highly," Dr Schnipper said. "I don't know if this is an unusual population, but to me, it's a signal that we may not really know all that we need to know."

The Patient's Perspective

Beverly Canin, a patient advocate and breast cancer survivor, again conveyed that patients may view value in factors other than cost. "Perhaps surprisingly, when you ask cancer patients if you think about value in cancer treatment, or when considering a cancer treatment how do you define value, cost is not the first thing they think of," she said.

For one thing, the word "value" itself may be puzzling to cancer patients. Ms Canin explained that since last October, she has been asking cancer patients about value in cancer care, and for the most part, the response was a quizzical look and a question: "What do you mean by 'value'?"

"When pushed to share the first thoughts that come to mind, they invariably referred to communication and the relationship they share with doctors," Ms Canin said.

In the study of metastatic breast cancer patients alluded to by Dr Schnipper, she pointed out that more than 38% of patients defined value in personal terms.[4] Only 7.4% defined value in terms of "an exchange," which was broken down to 1.95% as an economic exchange and 5.46% as health-specific.

Value may not be as clear a concept to patients as it is to policymakers.

"Most notably, of those with a health-specific exchange response, 76% described treatment benefit as being engaged by or feeling close to their healthcare provider," she said. "Financial cost relative to benefit or treatment efficacy was mentioned rarely."

Nearly 11% of patients indicated that they did not fully understand the questions, 3% reported "no value," and 46% did not answer the questions.

"Value may not be as clear a concept to patients as it is to policymakers," Ms Canin noted.

The Physician's Perspective

ASCO has transitioned from a focus primarily on the cost of cancer care, as indicated by a guidance statement issued in 2009,[5] to the more recent emphasis on value, explained Neal J. Meropol, MD, chief of the Division of Hematology and Oncology, University Hospitals Case Medical Center and Case Western Reserve University, Cleveland, Ohio.

"But a key point made in that initial statement was the importance of a discussion of cost and value with patients in helping them come to treatment decisions," said Dr Meropol, who presented the physician perspective on cost during the session. "I also want to make the point that the physician perspective is really the patient perspective, as best as we can understand it."

Patients are facing increased cost-sharing (eg, higher copays), rising prices of drugs and services, and greater complexity in navigating their care. Dr Meropol pointed out issues that some of his own patients had faced the week before the ASCO conference:

  • One patient declined adjuvant therapy because of cost and is unable to afford the antibody for metastatic disease;

  • Another missed an appointment because of insufficient funds for bus fare or taxis;

  • One patient needed to leave Dr Meropol's practice because of insurance changes; and

  • One patient had a delay in therapy because of logistics in obtaining an oral drug from the specialty pharmacy.

Although oncologists may not become gatekeepers on the basis of cost, commented Dr Meropol, oncologists can be gatekeepers in helping patients choose therapy on the basis of value. "Therapies that may have the same cost but differ in value; they may differ in efficacy and toxicity," he said.

In an interview with Medscape, Dr Meropol also explained how physicians can implement greater value on a day-to-day basis with their patients, without waiting for detailed guidelines.

"As a start, we all need to recognize that from a patient's perspective, value is more than just the potential benefit of a treatment in the context of its side effects. It is also the financial burden that will be placed on the patient and family," he said. "Given the high degree of cost-sharing that exists today with many health plans, our patients are really feeling the burden."

Recommending a lower-cost alternative without sacrificing clinical benefit is low-hanging fruit to improve the value we provide to patients, and to society.

His patients, Dr Meropol pointed out, are no longer saying, "Do everything at any cost." For this reason, he considers it important that oncologists are prepared to help patients understand the so-called financial toxicities of treatment. "Until I started thinking about this, I didn't realize that in some circumstances, treatments with similar outcomes have very different costs," he said. "Recommending a lower-cost alternative without sacrificing clinical benefit is low-hanging fruit to improve the value we provide to patients, and to society."

Dr Meropol emphasized that this isn't about rationing, but rather making rational treatment choices. "As a profession, we also need to find ways to ensure that all patients have access to high-quality care," he added.

For the future, he noted that physicians could benefit from new tools at the point of care that help assess the best treatment for their patients.

"It would be really helpful to have a point-of-care application that compares available regimens in terms of efficacy, side effects, and cost—not only the cost to society or to the payer, but the out-of-pocket cost for this particular patient sitting in front of me," Dr Meropol explained.

But most important is finding out what matters to the patient. "How can I best assess the goal preferences of my patient?" he noted. "And how can I best communicate treatment options to my patients, taking into account what they value?"

The Payer's Perspective

Payers are also part of the value proposition, and many have been looking at ways to improve care while lowering costs. Jennifer Malin, MD, PhD, staff vice president of clinical strategy at Anthem, Inc. (previously known as WellPoint, Inc.), who gave the "payer perspective" on value in cancer care, discussed the pathway approach that has been initiated at her company, in order to "highlight and reward high-quality care."

"We are often referred to as 'the payer' because we are an insurance company, but we are the not the ultimate payer," she explained during her presentation. "The ultimate payers are the employers and our members who pay for their insurance."

In 2013 the Institute of Medicine (IOM) published a seminal report that concluded that the cancer care delivery system is in crisis.[6] "The report found that care often is not patient-centered, many patients do not receive palliative care to manage their symptoms and side effects from treatment, and decisions about care often are not based on the latest scientific evidence," said Dr Malin.

Although the IOM made many recommendations to improve the quality of cancer care, three were particularly "salient," she noted. These were:

  • Establish a national reporting program with meaningful quality measures;

  • Improve the affordability of cancer care by leveraging existing efforts to reform payment and eliminate waste; and

  • Align reimbursement to reward affordable, patient-centered high quality care.

As an example, Dr Malin pointed to six treatment regimens that are currently considered to be standard frontline therapies for lung cancer patients who do not have mutations, such as EGF or ALK. There was little difference in outcomes among the regimens, and toxicities or morbidity differed only slightly. However, cost varied considerably, from $452 for four cycles of carboplatin/paclitaxel to $64,988 for carboplatin/premetrexed/bevacizumab.

"This is the situation where we see very big differences in value," she said.

The Cancer Care Quality Program was developed at Anthem to help provide access to quality and affordable cancer care, and a key component is the cancer treatment pathways.[7] Pathways take into account several factors, including clinical benefit (efficacy), safety/side effects (especially those leading to hospitalizations and affecting quality of life), strength of national guideline recommendations, and cost of regimens. There are now pathways available for more than a dozen cancer types, and oncologists who participate in the program are eligible to receive additional payment for treatment planning and care coordination when they select a treatment regimen that is on the pathway.

"Part of Anthem's commitment to members is to help them obtain the most optimal treatment plan for both quality and costs," she told Medscape. "The Cancer Care Quality Program is designed to focus on providing the best experience for our members in terms of quality of care, better quality of life, better outcomes, fewer side effects from treatment, and lower cost."

Dr Malin noted that the pathways are not available for every patient's medical condition but are intended to be applicable for 80%-90% of patients.

We need to have value in cancer care for all stakeholders.

The program began on July 1, 2014, and was initially be rolled out in Indiana, Kentucky, Missouri, Ohio, Wisconsin, and Georgia. It has since expanded.

The first set of pathways covered breast, non-small-cell lung, and colorectal cancers; Dr Malin reported that initial pathway adherence was 63% for both breast cancer and lung cancer, and 72% for colorectal cancer.

"We need to have value in cancer care for all stakeholders," she said. "We need to have quality, affordable cancer care; reimbursement for providers needs to be aligned to achieve desired outcomes; and we need to encourage clinically meaningful innovations. By highlighting those therapies that are most effective and bring the greatest value to patients, we also help to achieve that goal," Dr Malin summarized.


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