From the Editor in Chief: A Game of Risk

We are now in the longest, most dramatic period of cancer care innovation that we have ever seen. In the early days of cancer research, the victories came slowly, painfully, and at a pace that left far too many patients and their families seeking answers that would never come in time.¹ The initial dramatic victories achieved through the development of combination chemotherapy, increasingly precise radiation therapy, and more effective surgical strategies also came with the realization that even these marvelous technologies could not cure every patient. Over the past decade, however, we have seen the traditional anticancer armamentarium grow in extraordinary ways, with new technologies that were targeted with increased precision against the molecular and protein biology at the core of cancer. With the advent of highly effective therapeutics like the tyrosine kinase inhibitors, monoclonal anticancer antibodies, checkpoint inhibitors, and the rapidly growing myriad of gene-mutant targeted agents, patients’ hopes for more effective treatments and a greater chance for cure (or long-term containment) of their cancer are increasingly realized.

Yet, what is it about this extraordinary period in cancer care innovation that is so disquieting? Inasmuch as the promise of increasingly effective cancer care brings a growing sense of hope, the extraordinary growth of the costs of delivering this care provokes anxiety about whether these therapies can be delivered in a financially sustainable, equitable way. Many, including authors in Evidence-Based Oncology™ (EBO™), have written about the growing level of healthcare expenditures in the United States ($3.3 trillion in 2016)² and the extraordinary costs of new targeted anticancer drugs (as of 2014 the average monthly cost for a new anti-cancer oral agent was $11,325)³. These factors, coupled with the rise in patient-borne costs of cancer care and the resulting “financial toxicity” crisis⁴, beg the question of how can we restore order, equitability, effective access, and financial sustainability to our care delivery system?

It is impossible to imagine that any single “magical” fix to the healthcare system can make any of these issues go away. Moreover, the current level of political rhetoric surrounding the question of “fixing” the ills of the healthcare system is more likely to provoke gastrointestinal distress than real, meaningful systemic change. The hope of getting this right lies in the ability of the key healthcare stakeholders to more effectively align patient risk, therapeutic strategy, and reimbursement in a way that more effectively rewards better, more effective care, while ensuring that those healthcare systems/providers who provide appropriate care for high-risk/high-cost patients are not penalized financially for doing so. In their seminal article, “The Strategy That Will Fix Health Care,” Porter and Lee review a series of systemic realignments in care delivery that could help to address the issue of financial sustainability while also allowing for better transparency (and financial rewards) for delivering excellent care.⁵ This clinical/quality/financial realignment is one in which those providing care accept financial risk in the process, but do so in a way that is financially sustainable and provides an effective reward system for doing it well.

While we understand the right sensibilities in creating a sustainable care delivery, we have not yet created the ideal model for delivering this consistently, at scale, across a nation of more than 325 million individuals. We do, however, have evidence of progress in this pursuit through the development of advanced alternative payment systems (AAPM). The Medicare Access and CHIP Reauthorization Act (MACRA) has helped push physicians and care systems into greater numbers of 2-sided risk—bearing payment models in the hopes of better aligning reimbursement with effective care delivery. While the number of initial AAPM choices for oncologists under MACRA were quite limited, we are beginning to see growing numbers of new, innovative models gaining acceptance by the Physician Focused Payment Model Technical Advisory Committee (PTAC).⁶ What some of the emerging models have in common include rigorous financial risk-grouping of patients around both diagnosis and clinical risk, alignment of financial risks around costs that physicians can actually control, and more meaningful outcome measures than those used in the current Physician Quality Reporting System (PQRS).

In this month’s issue of EBO™, we examine some of the innovators in the cancer care domain. Kashyap Patel, MD, and his coauthors review the practice transformation at Carolina Blood and Cancer Care Associates, in addressing the issues of adapting to 2-sided risk and expanding patient access. In a paper from the Network for Excellence in Health Innovation, we review the concept of value-based contracting for oncology drugs. A pilot program between Regional Cancer Care Associates and New Jersey’s largest payer that will use COTA clinical risk assessment software will create a template for more effective care delivery using nurse navigators.

Inasmuch as innovations in care technology promise patients greater hope when faced by a life-threatening cancer, innovation in the care delivery and payment systems may help create new strategies for delivering this care sustainably. Although the idea of a chimeric antigen receptor (CAR) T-cell therapeutic costing more than $400,000 is a new reality, a fundamental realignment of our care and payment system around the patients’ needs can help ground us in ensuring that those patients who need and will benefit from these technologies can receive the best care possible.References

1. Mukherjee S. The Emperor of All Maladies. Scribner. New York, NY. 2010.
2. Centers for Medicare and Medicaid Services. National Health Expenditure Data. CMS website. cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NationalHealthAccountsHistorical.html. January 8, 2018. Accessed April 9, 2018.
3. Silverman E. Cancer drug prices are high at launch and stay that way. Stat website. statnews.com/pharmalot/2016/05/02/cancer-drug-prices-keep/Published May 2, 2016. Accessed April 9, 2018.
4. National Cancer Institute. Financial toxicity and cancer treatment PDQ health professional version. cancer.gov/about-cancer/managing-care/track-care-costs/financial-toxicity-hp-pdq. Published January 30, 2018. Accessed April 9, 2018.
5. Porter M, Lee T. The strategy that will fix healthcare. Harvard Business Review. hbr.org/2013/10/the-strategy-that-will-fix-health-care. Published October 2013. Accessed April 9, 2018.
6. Pecora A, Hervey J. Oncology bundled payment program using CNA-guided care. HHS website. Hackensack Meridian Health System and Cota Inc. aspe.hhs.gov/system/files/pdf/255906/OncologyBundledPaymentProgramCNACare.pdf. Submitted March 24, 2017. Accessed November 27, 2017.