ASCO's Yu Outlines How the "Changing Value Proposition" Is Redefining the Oncologist's Role

The rising cost of cancer care in the United States, and the need to listen to what cancer patients want, is not only transforming the way Americans deal with health insurers, but also the way physicians practice medicine, Peter P. Yu, MD, FACP, FASCO, president of the American Society of Clinical Oncology (ASCO), told a multistakeholder meet at Patient-Centered Oncology

Care 2014.

Yu gave the morning keynote address, “Value in Cancer Care: Achieving Patient Centered Care in Today’s Environment,” which offered the providers’ view to the third annual gathering of payers, providers, policy leaders, and representatives from the pharmaceutical sector sponsored by The American Journal of Managed Care. The meeting in Baltimore, Maryland, aimed to seek better solutions for cancer patients at a time when patterns of insurance coverage are changing, and as payers demand proof that new therapies are worth the high cost.

The changing value proposition is causing oncologists to ask, “What does it mean to be a doctor in the United States?” Yu said in opening his talk. A physician, he said, can no longer be someone who does things to patients, but must be someone who does things with patients to try to achieve an outcome. Yu emphasized that the cancer patient must be part of the decision-making because the implications of care have changed so much.

WHERE IS THE VALUE?

Citing an Institute of Medicine report, Yu reviewed elements that are driving up healthcare spending in the United States without adding value: $210 billion in unnecessary medical interventions, $190 billion in excess administrative costs, and $130 billion in inefficient care delivery. He dubbed this, “Doing the right thing, but doing it the wrong way.”¹

To stop this trajectory, healthcare reformers seek to measure quality. However, “We don’t really have robust outcomes measures, and this is a major problem,” Yu said. “If you don’t have outcomes measures, how can we decide what value is? We focus mostly on process measures.” In cancer care, diagnostics have added a new, expensive element to the cost equation. “Diagnostics are as important, if not more important, than therapeutics because they increasingly drive the decision for therapeutics,” Yu said.

COSTS CANNOT BE IGNORED

The ASCO president said the rising cost of cancer care has changed the dynamic between doctors and patients. Historically, discussing the price of therapy with patients was verboten for physicians, but in 2014, ASCO took on the dual issues of value and quality as priorities. Last spring, CMS agreed to use ASCO’s quality standards as a clinical data registry. ASCO collected data from payers and engaged in extended discussions, and the group is now working with Congress to redesign Medicare reimbursement to be less complex and to reward quality.

There’s simply no avoiding that rising prices for specialty drugs are the biggest cost drivers in cancer care, Yu said. He shared data from Blue Cross Blue Shield Association showing a 900% escalation in cancer drugs between 1996 and 2010, and data from PriceWaterhouse Coopers showing that the current $87.1-billion expenditure on specialty drugs is expected to quadruple

by 2020.

On a more critical note, out-of-pocket costs for patients are rising: 34% of employers now charge at least a $60 co-pay for specialty drugs. How does that play out in cancer care? It means a patient who needs to take 1 pill a day for chronic myeloid leukemia might take that pill every other day, and that person becomes likely to relapse when there’s no reason for that to happen, Yu said. “We need to consider more than the price of the drug,” he said. “We need to consider using or not using the drug.”

At the practice level, regulatory pressures, the price and delivery of cancer drugs, and the trend toward consolidation have made it difficult for small oncology practices to stay afloat, Yu said. This can hurt access to care in rural areas, where the community oncology clinic may be the only option. Clinical care pathways, which payers use to control the costs, can be designed with software that incorporates patient preferences, Yu said. He was optimistic about the role of Big Data in the future of cancer care.

Yu then discussed principles of the payment reform initiative that ASCO is pursuing with Congress:

• Reimbursement must not only move away from fee-for-service toward value, but also from the idea that payment must be tied to the physician touching the patient. Work by nurses, nutritionists, and other team members is essential and should be reimbursed. • Contact with the patient outside the office visit—especially during the survivorship stage—needs to be recognized.

• Flexible payment models must match the transition to valuebased care. Excessive documentation is wasteful. Documentation should be streamlined and predictable.

• A model advocated by ASCO trims codes from 58 to 11.

• A bundled model can work, but the period of the bundle should be 1 month, since cancer patients’ status can change rapidly.

• The model must support clinical trials and transitions in care.

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