Balancing Cancer Treatment Innovation and Economic Burden

New cancer therapies that improve outcomes and survival are great for patients, but they bring economic consequences, and oncologists must find a balance between providing the best care and not spending too many health care dollars, said Glenn Balasky, executive director of Rocky Mountain Cancer Centers (RMCC), as he opened the October 5, 2022, session of The American Journal of Managed Care®’s Institute for Value-Based Medicine®. The event took place in Englewood, Colorado.

Ken Cohen, MD, executive director of translational research at Optum Care, kicked off the night with a presentation on merging evidence-based medicine with data and analytics to expunge wasteful care from the system.

Cohen’s chief takeaway: Not only is there no relationship between cost of care and quality of care, but “very often, they are inversely related.”

He shared a cost/quality scattergram of 1-year survival rates and total inpatient costs for Medicare beneficiaries with myocardial infarction, colon cancer, and hip fracture,¹ which showed that when plotting cost and quality of physicians, only a few are practicing at what he called the “optimal intersection of both quality and efficiency.” The goal of Optum Care’s OptimalCare Model is to drive health care to that ideal intersection.

The poster child for illustrating low-value care is the thyroid cancer experience of 1999 in South Korea, in which the government decided to screen the entire population for thyroid cancer. However, the mortality for thyroid cancer was essentially zero. “Why would you design a cancer screening program for a cancer that [is associated with] no mortality? It’s hard to understand that,” Cohen said.

Over a decade, there was a 13-fold increase in the diagnosis of thyroid cancer, many of which were indolent thyroid cancers that never should have been diagnosed. The result is that some patients underwent harmful care, such as thyroidectomy. “As you [can] imagine, thyroid cancer mortality didn’t change at all,” he said.

The Optum Care OptimalCare Model recognizes that the solution to reducing low-value care must be led by physicians who are aligned with a physician-driven solution. It includes provider-focused, evidence-based education to help drive decisions and to bring together patients and providers for shared decision-making, so that patients understand the real-world outcomes of the care they’re seeking.

Among the many examples of shared decision-making was one on breast cancer screening. Optum Care put together a document to educate women about when to start screening: at age 40 years or 50 years? The piece also included the pros and cons of starting at each age. One woman might look at the information and decide to start screening at age 40, while another will decide to wait until age 50.

“There’s no right answer, as long as they make decisions based on good-quality information,” Cohen said.

However, breast cancer imaging centers are marketing this decision differently.² About 80% of imaging centers market mammographies to start at age 40, and few market mammographies to start at age 50. Less than 20% recommend any shared decision-making at all.

Finally, Cohen discussed the use of analytics in the OptimalCare Model. Analytical reporting is easy for a primary care provider (PCP) but is difficult at the specialty level, he explained. The PCP deals with diabetes, hypertension, hyperlipidemia, and cancer screenings, and a handful of metrics can be used to regularly follow the population being cared for.

These claims-based metrics are collected to create a performance report, which is transparently shared. Individual PCPs can be compared with peers in their region over the course of time.

Can this be done for oncology? A model isn’t built out yet, but Optum Care is working on one focused on patient outcomes, cost of care, and site of service. The metrics being considered include total cost of care, use of biosimilars, emergency department and hospital utilization, and optimal use of palliative care and hospice care late in the course of disease.

A Focus on Site of Care
Site of care and cost of care are things community oncology does well, said Lalan Wilfong, MD, vice president, payer relations and practice transformation, The US Oncology Network.

For the first time, cancer is the top cost driver for employers.³

“It’s not fun being No. 1 in these settings, because when you’re No. 1, you get a lot of the spotlight,” Wilfong said. “And we have to start thinking about, ‘How do we manage this cost of care more effectively?’”
Right now, employers are focused on site of care management, because they want to identify the places where they can get the best value for the services provided. They’re interested in second-opinion services, which tend to lower the overall total cost of care.

Payers are also looking at policies related to site of service and trying to identify where they can direct patients to receive higher-value care.
Research results have shown that site-of-service cost differences emerge when comparing care in the hospital vs care in the community setting.⁴ A review of patients with breast, lung, and colorectal cancers found that, on average, care in the community cost $12,548 compared with $20,060 in the hospital setting. And 340B hospitals are even more expensive.⁵

“So, it’s right for employers, for health plans, for [primary care provider] groups to start asking, ‘Why am I paying this much more money to get the same level of care that I can get in a community-based center and a much better value?’” Wilfong pointed out.

The community practice approach to value includes numerous strategies, including the use of less expensive but equivalent medications, such as biosimilars; a focus on generics; and the use of advanced care planning and end-of-life support to drive down total cost of care, he said. Pathways, which are evidence-based and reduce variation, and state-of-the-art technology, which can deliver and attest to high-quality, cost-effective care, are also areas of focus to drive value.

Reviewing RMCC’s quality performance in the Oncology Care Model, Wilfong highlighted that the practices were in the top quartile for hospice utilization before death. In addition, they had top quality scores, with inpatient visits down from 25.9% in performance period (PP) 1 to 17.9% in PP10, and emergency department (ED) visits down from 25.0% in PP1 to 21.3% in PP10.

“[There was] a marked reduction in ED visits,” Wilfong said. “Is that good enough? No, we’re just getting better. And they’re actively working on continuing to improve that.”

A Tool to Understand Risk
RMCC’s value-based care program also looks at whether treatment is appropriate for certain patients. The practices have implemented an assessment tool from the Cancer and Aging Research Group (CARG) to review if a patient is high risk. If they are, the oncologist can help them understand the risks of chemotherapy before they elect to move forward with treatment.

According to Alonso Pacheco, MD, RMCC’s medical director and a medical oncologist/hematologist there, this tool provides an opportunity to have an intervention with the patient to drive a different type of behavior, and it has led to initial dose reductions that would otherwise not have occurred.
A Yale University study of the CARG tool has shown that it led to a decision to dose attenuate in 32% of cases and to a different regimen in 15% of cases.⁶ “CARG is a valuable tool” that usually takes only 5 minutes to conduct, Pacheco said. However, it requires having alternative options for patients should they choose not to receive chemotherapy after seeing their CARG score. RMCC has partnered with a local hospice company medical director to increase access to hospice care for patients, improve control of their neoplasm-related pain, and improve the transition to home hospice when the patient is ready, Pacheco added.

CARG is also now included in the National Comprehensive Cancer Network (NCCN) guidelines. In 2021, NCCN added the CARG Chemo Toxicity Calculator as a consideration to its Older Adult Oncology guidelines because of chemotherapy’s toxicity risks.⁷

The CARG tool requests some basic information, such as age, height, and weight, as well as clinical characteristics. It also asks some functional questions, such as if the patient can walk a block, how easy it is to take their medications, and how many times they’ve fallen in the last 6 months.

When physicians near the end of life, they spend an average of 2 months on hospice, Pacheco said; however, most patients spend less than 3 days. In 2022, RMCC had 98 eligible patients with 25 on hospice; some spent more than 100 days on hospice.

“We have a tool that allows us to track the most valuable decision in medical oncology,” said Pacheco. It helps decide appropriately to not give chemotherapy to patients who will not only not benefit from it, but who might actually get sicker from it, he continued.

Currently, Anthem is reimbursing for this service, and RMCC is collaborating with other commercial payers to update contracts for reimbursement to utilize the CARG tool. However, other barriers to using the tool exist besides reimbursement. For instance, the tool is not validated for newer treatments, such as immunotherapy and oral targeted therapies.

Research confirming the tool’s value, however, is out there, Pacheco said. Yale University found that 65% of oncologists can complete the tool in 5 minutes or less, and 88% can complete it in 10 minutes or less.⁶ Ultimately, 89% of oncologists said calculating the CARG score was worth the time spent on it. In addition, a study from Kaiser Permanente Northern California found that the CARG tool predicted the risks of ED visits, hospitalizations, and mortality in patients 65 years and older.⁷
“How do we move this along from early adopters to broad acceptance?” Pacheco asked. “That’s our challenge.” 

References
1. Institute of Medicine (US) Roundtable on Evidence-Based Medicine; Yong PL, Saunders RS, Olsen L, eds. The Healthcare Imperative: Lowering Costs and Improving Outcomes. National Academies Press (US); 2010.
2. Patel NS, Lee M, Marti JL. Assessment of screening mammography recommendations by breast cancer centers in the US. JAMA Intern Med. 2021;181(5):717-719. doi:10.1001/jamainternmed.2021.0157
3. 2023 Large Employers’ Health Care Strategy Survey: introduction. Business Group on Health. August 23, 2022. Accessed November 14, 2022. https://www.businessgrouphealth.org/resources/2023-large-employers-health-care-strategy-survey-intro
4. Gordan L, Blazer M, Saundankar V, Kazzaz D, Weidner S, Eaddy M. Cost differences associated with oncology care delivered in a community setting versus a hospital setting: a matched-claims analysis of patients with breast, colorectal, and lung cancers. J Oncol Pract. Published online October 31, 2018. doi:10.1200/JOP.17.00040
5. Examining hospital price transparency, drug profits, and the 340B program 2022. Community Oncology Alliance. September 12, 2022. Accessed November 15, 2022.
https://communityoncology.org/featured/examining-hospital-price-transparency-drug-profits-and-the-340b-program-2022/
6. Mbewe A, Pike P, Lewis R, Kortmansky JS, Chiang AC, Kanowitz J. Implementing the Cancer and Aging Research Group (CARG) tool in the ambulatory oncology setting to drive informed treatment selection. J Clin Oncol. 2021;39(Suppl 28):abstr 209. doi:10.1200/JCO.2020.39.28_suppl.209
7. Arora A, Sun H, Shaia JL, et al. Using G8 and CARG toxicity score to predict emergency room (ER) visits, hospitalizations, and mortality in older patients with newly diagnosed cancer. J Clin Oncol. 2022;40(Suppl 16):abstr 12055. doi:10.1200/JCO.2022.40.16_suppl.12055