Is the 'Value' Movement Affecting Everyday Oncology Practice?

Kathy D. Miller, MD; Leonard B. Saltz, MD; Lee S. Schwartzberg, MD


July 18, 2019

This transcript has been edited for clarity.

Kathy D. Miller, MD: Hi, it's Dr Kathy Miller, from Indiana University. Welcome to this edition of Medscape Oncology Insights. I'm joined by two good friends, Dr Len Saltz, a medical oncologist at the Memorial Sloan Kettering Cancer Institute in New York, and Dr Lee Schwartzberg, medical director for West Clinic in Memphis, Tennessee. Thank you both for coming in today.

We've been hearing a lot about a shift in medical practice from fee-for-service to affordable care organizations and value-based care . I wanted to talk to you both about how that shift in the focus on value has impacted practice, from community practice to the academic setting.

Len, I know you've thought a lot about this when it comes to the cost of new drugs, but how else has that shift impacted what we do?

Heightened Focus on Value

Leonard B. Saltz, MD: One of the things that is starting to happen is that everybody involved in cancer care—the patient, caregivers, and doctors—are becoming aware of costs. They are starting to ask, "What are we getting for it?" They are looking at cost both in terms of financial cost and as a patient toxicity, and we're starting to see people at every level thinking more and more about the pluses and minuses of a particular intervention for the patient : Is this a good idea? Is this worth it?

And more broadly, people are starting to think at the level of a population and cancer community, "Is this worth it for us? Is this a good idea?" That is a very substantial change in thinking that has been creeping up on us over the past decade and is really becoming quite strong.

Miller: For many decades, we really didn't pay any attention to cost; we focused only on the improvement in outcomes. When I was a fellow, my mother asked what it cost for somebody to come see me. I had absolutely no idea. But that was definitely not the case in private practice, where I went when I first left fellowship. I remember monthly meetings where we looked at the detailed finances, what different drugs cost, and what the markets were. This has got to be an even bigger change in the private practice arena, right, Lee?

Lee S. Schwartzberg, MD : Yes. The cost of drugs and all services around cancer care have gone up, and we're now in a place where every new drug launches at more than $100,000 per year. There has been a fundamental shift and a lot of growth. Paradoxically, we're also in an era where care is better and, excitingly, we're seeing better results. People stay on therapies longer, which increases the cost to the system.

But we all know healthcare is too expensive. Cancer care is very expensive. How do we get value —meaning, how do we get quality for a particular cost? In some cases in the community as well as the academic setting, that [conversation] has been driven by the government and the oncology care model, which I think has had a profound effect on the way people are starting to think about value in cancer care. Private payers are following suit as well.

What Is Value in Care?

Miller: What is value in care? How do patients know that they are getting value for the money they spend or someone spends on their behalf?

Schwartzberg: I can't speak for every patient, but I think they perceive value as having a good experience with their care team, meaning they receive compassionate care that is knowledgeable.

We use the term "patient-centered care" a lot, and we're still on a journey to make that happen. Focus on what the patient needs, give them alternatives for therapy, and give them what is best for them. Sometimes values are different in terms of efficacy versus cost versus toxicity. Knowing all those things are important.

Make sure that a care team is available to them day and night so they don't feel alone in this very difficult journey, and make sure that all of their needs are taken care of. That is what a patient perceives as value, for the most part.

Miller: Do you see the same thing in the academic setting?

Saltz: I think so. We can look at it from a number of different ways, but at the end of the day, a patient is a human being with cancer, and that human being is being taken care of by a doctor, whether in an academic setting or in a private practice setting. The fundamental focus is the same: There is a person with a disease, they need help to combat that disease, and they need to live with that disease as best as they can.

Understanding who the patient is and helping them understand their choices is a critical part of maintaining a high level of value in care.

Within that context, value is basically a ratio of the benefits to the detriments. If we can increase the benefits without increasing the detriments, we increase the value. If we increase the detriments without increasing the benefits, we decrease the value. Cost is not the only detriment; toxicity of all sorts is certainly a detriment.

And getting into what Lee is saying about focusing on the patient, the same negative effect may affect one individual more than another. One may be more concerned about the finances involved, whereas another may be more concerned about a particular toxicity. Hair loss, for example, may matter a lot to one person, but not at all to another. The issues of neuropathy and loss of fine motor skill may be a minor annoyance for one person and may be very dramatic for another person in terms of interfering with their work or what they do for fun and recreation. Understanding who the patient is and helping them understand their choices is a critical part of maintaining a high level of value in care.

Incorporating Care to Increase Value

Miller: How have your own institutions tried to incorporate some of the aspects of care that have shown increased value? Certainly, increased benefits don't add detriments, but they also don't fit into a lot of reimbursement models—for example, things like Ethan Basch's work with patient-reported outcomes,[1] or the early involvement of palliative care teams that lead to people getting generally less chemotherapy, having less toxicity, and living longer.[2] It's hard to imagine that something giving you those three is not valuable, but it's been difficult to put that sort of work into practice because it does not fit into our systems. Have either of you found a way to do that? I have to admit that is something my own institution is still very much struggling with.

Schwartzberg: I was very excited to see Ethan's work. We've been involved in patient-reported outcomes using digital tools for about 15 years.[3] The problem, as you state, is that it's not reimbursed. But it can be very valuable to people, and it's very valuable to the care team as well. Just simply measuring patient-reported outcomes, such as common symptoms, and alerting the care team that they exist actually led to a survival advantage. If that was a drug, it would be incredibly [expensive].

Miller: It would be $100,000 per year.

Schwartzberg: So, why isn't everyone doing it? That study was a turning point, but it's still not completely incorporated. But if you talk to people in this value-based arena, there is interest in patient-reported outcomes. There is definitely interest in the patient experience as part of the quadruple aim : for example, what the patient feels is important. Measuring these things and trying to identify symptoms and providing palliative care early help patients live better lives. We now have level 1 evidence that that is true.

Improving Value of Care in the Real World

Miller: Have you been able to use those things in your clinics, Len?

Saltz: We're working on the basic concept. If you think about patient-reported outcomes, it is a facilitation of communication. It's making sure that the patient has access to the care team and vice versa, so that there is a back-and-forth flow of information, rather than somebody sitting at home with a problem and unaware of how to deal with it, or showing up to the clinic without background information and we find out a problem has been going on for a long time.

No, we have not institutionalized formal electronic reporting, although there is a lot of work being done and there is a whole area of investigation on using electronics to try to facilitate communication between the patient and the caregiver team. The concept is nothing new. It really is validation of the fact that it's a partnership between the patient and the care team, and good communication back and forth is going to be valuable to the patient and increase the value of interactions.

You brought up one very interesting point, which is that a lot of improving value in care is not doing things that are either low value or have a negative value. When we talk about communication, it also means finding ways to communicate bad news. It means finding ways to help people understand what isn't possible and what is the best alternative under the circumstance, rather than offering unrealistic expectations about an intervention that may have substantial cost in terms of negative impact on the patient, as well as financial costs without benefit. Helping people to make rational, intelligent choices rather than desperate and wishful choices can greatly improve the value of care across the board.

If we have poor- quality data or insufficient data, we can't assume that there is value to the intervention.

Schwartzberg: We're also thinking a lot about reducing variation, which is probably more common in a community-based setting. Most community oncologists are generalists, but there is a move to subspecialize. In an academic institution, you might see someone who specializes and sees only gastrointestinal cancer, but that is simply not possible if you're in a small group where you have two or three physicians who have to see the entire gamut frequently not only of cancer, but also of benign hematology. Today, the information explosion is such that no one can keep up on this.

We need tools to [help ensure] that the right decisions are made, or at least offered to the patient, and that all the exciting advances we see at the American Society of Clinical Oncology annual meeting are translated quickly into the community and into every center so that a patient can get the benefit of the best therapy anywhere they are. One way to do that is with pathways.

Saltz: I'm going to agree with that, but with a caveat : It's very important to get the best information to the patient as quickly as possible, but it's also important not to rush the process beyond what can be accomplished. We face a flood of information, misinformation, and disinformation on the Internet and elsewhere, where patients are led to believe that something has dramatic benefits when that has not been established. Small studies may suggest benefit, but larger studies that may refute this may be in progress or have not addressed the question yet. For example, the degree to which molecular profiling has an impact, and the degree to which it does not, needs to be understood for each patient with each tumor type at each stage. You need it for one type of cancer at certain stages, but it may not actually have a role in routine practice yet in other types of cancer or other stages.

Similarly, how and when to make use of cell-free DNA and circulating tumor cells and whether they part of standard practice or not are the types of things that we have to be very clear about

in our communication with patients. It's high value when we've got good- quality data to show us that it is. If we have poor- quality data or insufficient data, we can't assume that there is value to the intervention.

Evaluating Outcomes

Miller: You bring up an interesting point, because our tendency is to focus on treatments and drugs, but there are a lot of things that go with that. There are also differences in use of supportive care medications (eg, growth factors) and monitoring of blood tests or imaging. I don't think I can turn on the radio without hearing about a cancer center that could sequence my tumor faster, deeper, or better than someone else.

Saltz: Or teach your immune system to fight it.

Miller: And it's always implied and sometimes frankly stated that patients will have a better outcome because they have done those things. That must drive you crazy when you see those advertisements.

Schwartzberg: With the advent of direct-to-consumer advertising, patients come in wanting a new drug whether it fits them or not, particularly as we've seen the explosion of immunotherapy and the competition between cancer centers to promote the next new thing which will help patients. There is a lot of noise out there, and Dr Google does not help. So, our job as physicians is to cut through that. I agree completely that it has to be evidence-based and when there is clear evidence, that is what we should be recommending to our patients.

What we have not gotten to yet in terms of value is having the data analytics to really answer the question, "What are your outcomes?" It's very easy to have an advertisement that says, "We can do better because we have this great technology or this great radiation treatment that no one else has." But what are the outcomes? What are you really getting out of it? I think we're at the dawn of an era where payers and potentially the government might be interested in a way of measuring outcomes that is uniform, so that we can see the survival outcomes at every center. Some centers publish their 5-year survival, but you have to be careful; is it really including everyone? Is it risk adjusted? It's not a simple matter to even compare outcomes directly from one institution to another.

Miller: If we had that, it would also then let you identify institutions or practices that have better outcome-to-cost ratios or achieve the same outcome with much less cost. This could be a very powerful tool if we're looking at both what they are doing and what they are not doing. Some of the things we've identified —many of which get listed on the Choose Wisely campaign each year—are a first effort to get us to stop doing some things that are not useful.

We're going to have to be stop doing things that don't provide value.

Schwartzberg: Hospitals now have to report certain outcomes for certain programs, and I think we'll see more and more of that over time. There is a cost to generate those outcomes. You have to invest in data analytics platforms—which can be difficult in a community setting—but I think that will be the price of admission going forward. It's the right thing to do, because, as you asked, why do patients have less information about medical care than they do about so many other aspects of their life, when health is such an important piece of it?

Miller: It's a sobering thought to think about academic tertiary referral centers and how to evaluate those outcomes. For example, not everybody with breast cancer in Indianapolis makes their way to me. It's a select group of folks. And in many ways, they have to be sicker and more complicated before someone thinks about referring them to me. That must be a concern at Memorial Sloan Kettering as well.

Saltz: I'm sure it's going to be a concern across the whole continuum of cancer care, because we have a situation where state-of-the-art technologies being brought to bear at the academic centers may be more expensive. We have a situation where people coming to these centers may be expecting treatment deeper and deeper into their care, and we have to figure out how to manage those expectations and keep people from getting treatments that are not going to be of value and benefit to them. There are no simple solutions. These are definitely problems that we're starting to focus on more and more.

Getting back to one of your first questions about value and how you define it, I was asked that question almost a decade ago on a panel, and I said, "Ultimately, I think we're going to wind up defining value by its absence. We're going to have to be willing to define where it's not [valuable] and willing to say that it's not in order to stop doing things that don't provide value." We've been very reluctant to do that. We've been working under the very comfortable assumption that everything we do, if done with the best of intentions, has value. But that does not hold water if we stop to look at it and put our feet to the fire and ask, "What is the benefit we can realistically hope for?"

The word "realistically" is important to underline, because we have to get away from the lottery ticket mentality of "Hey, you never know, this might work," and start looking at "What might it do negatively, and what are the odds of it helping, and how much can we really ask anyone to undergo that kind of risk?" These are the types of calculations that we have safely put under the table because it's more comfortable that way. But for many reasons, we simply can't afford to continue this.

Miller: It's finally starting to happen. The two things I continue to hear are measuring the right things so that we can actually [determine] value and outcomes, and communicating with our patients, payers, and amongst ourselves as a professional society to make critical decisions about value and what we should or should not be doing. I think we're very much in the infancy of this area, but it's exciting to see those discussions continue.

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