Cancer Care Value-Learning From Others

As of March 2, 2012, there were 395,000 available apps for the Android phone, with 278,000 of those being free.¹ The iPhone has over 578,000 as of February 27, 2012, with 222,000 free.² The developers seem to have it figured out. I tend to pursue “free” apps only, but then find myself spending tens of dollars in fighting and avoiding advertisements. The $0.99 app of the same is likely free of such and therefore a valuable saver of time: the most precious resource. I also find it very ironic that even the “free” apps get reviewed and scored. It is very rare that we are asked to rate or score free items. Can you imagine driving down the interstate entering another state and suddenly being asked to evaluate the air— and not being able to leave the state or use an exit ramp until you do.

A recent evening snack also reminded me of another value “trick” that has befallen us: the beloved “half gallon” of ice cream that is no longer. The typical size of a carton of ice cream is now 1.75 quarts—a reduction of 1/8. When did that happen, and which rock have I been under? And it is not just ice cream. Candy bars, coffee, and toilet paper are further examples of lowering the quantity without lowering the price. The next evolution of these marketers is increasing the size with a greater than proportional price increase and calling it a “value size.”

Another example is the flood of commercials for gold, from “sell your grandmother’s gold to us for the best price” to celebrities telling how they have converted all of their assets to gold. I was perplexed with all of the sudden interest in these nuggets from the earth. It then dawned on me that all of this recent activity was created by the Gold Sellers Union in order to push up the demand for gold and thus increase the price. After all, isn’t there a limited supply of gold? When pondering the value of cancer care and how it is determined, I was struck by the difficulty of creating, defining, and promoting the value of quality cancer care. If we try learning from other industries, we should be able to do something like the following:

“Our cancer treatment was voted best by all cancer patients and their families. Use our free treatment or upgrade to our less-advertised version of treatment for only $10,000.” The advertisers would be subsidizing all of the treatments, free or not, and the subsidy would come from pharmaceutical companies, supply vendors, et cetera. Oooops, I forgot, this has already been determined to be illegal. Again, too much time for me under the rock.

Applying the above to our world, we could reduce the usual dose for specific cancer treatments, continue to promote that treatment, and then increase the dose to normal amounts and follow with promotions of “Value Dose.” Yep, you are right, not a good idea, and counterproductive to what we are here to do.

We do seem to have a real example of how increasing the demand does not necessarily increase the price. Consider the ongoing chemotherapy drug shortage issues. Most of current shortage drugs are generic, typically the least expensive in their class. Spontaneous increases in their costs, for regulatory or production reasons, are not matched with provider reimbursement due to the 6-month lag built into the ASP reimbursement system. This is an unexpected result of implementing unnatural forces into a world that is accustomed to natural market forces.

So why is it so hard to define, measure, and promote “value” in cancer care? My healthcare marketing professor said it best in describing the uniqueness of healthcare. It is one of the only industries where the consumer, decision maker, and purchaser are 3 different people. (This coming from the same professor that indicated Ferrero, the manufacturer of TicTacs, was actually selling “fun” and not breath mints.) The major stakeholders in our world are the patient (the consumer), the provider (the decision maker), and the payer (the purchaser). Each has their own list of priorities as well as their own subset of stakeholders. Upon close review, their priorities seem similar but not necessarily aligned.

Cancer patients are supported by their families, friends, and employers. According to a recent gathering of major stakeholders, the things patients desire from the care team include access, ability, affordability, affability, and availability. They also anticipate quality and timely communications, honesty, and the best possible outcome with the best possible quality of life. Additionally, they request the least amount of pain, toxicity, and test results.

Providers are not much different. They are surrounded by clinicians, advocate organizations, and networks of other providers and diagnostic facilities. They also want satisfied patients and families, best possible outcomes, minimized administrative burdens, a fair reimbursement for all of the services provided, and positive incentives to continue all of the above. Quality of life is paramount.

And are payers much different? It does not sound like it. Although they are accountable to their stockholders or taxpayers, they also desire similar outcomes. They want member satisfaction, the best possible clinical outcome, the highest quality care in the lowest cost setting, treatments for members that are cost-effective and evidence-based, and meaningful indicators of quality and value.

The common threads between these 3 major groups of cancer care stakeholders are patient and family satisfaction and measurable value. The challenge is to define these attributes so that they are measurable, relative, and aligned between all care providers and stakeholders. We do not have the luxury of being able to call on advertisement sponsorship, or to adjust the package size, or to artificially inflate demand—nor would we want to. So then, how do we become united in our efforts, definitions, and recognition?

The recent gathering of 16 representatives from the various stakeholder groups is a great start. These individuals have crossed competitive lines from their payer, provider, or group purchasing worlds to collaborate on solutions that will benefit the patients, their families, and one another. They recently met in Atlanta to collectively address this issue with collaborative, open, and honest communications. The goals are evident and obvious but the obstacles are real. Standardizing and measuring patient and family satisfaction is the simpler of the 2 and great strides have been made to implement and report this information across all specialties. However, the value proposition is much more difficult. One payer said it best—they cannot easily and arbitrarily pay a single provider group for higher quality or value. Everything has a cost, even in the above-mentioned scenarios. Our approach should be no tricks but instead transparent positive incentives to encourage, promote, and recognize quality and value. The industry leaders that were seated at the table on those 2 days believe that this can be accomplished and in a way that all stakeholders may benefit. Once the value proposition is defined, we will be able to redefine ageold payment systems so that all value and quality will be evident and rewarded. Are we there yet? Not yet, but if the same creative and passionate minds that are working on this issue were also involved in the ice cream decisions, we might still have a full half gallon of cookies and cream.Author Affiliation: From Strategic Practice Initiatives, Community Oncology Alliance, Washington, DC.

Funding Source: None.

Author Disclosure: The author reports no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design; acquisition of data; analysis and interpretation of data; drafting of the manuscript; administrative, technical, or logistic support; and supervision.1. AppBrain website. http://www.appbrain.com/stats/. Accessed March 9, 2012.

2. 148Apps.Biz website. http://148apps.biz/appstore-metrics/. Accessed March 9, 2012.

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