Cliff Goodman, PhD; A. Mark Fendrick, MD; John L. Fox, MD, MHA; and Ira M. Klein, MD, MBA, FACP
Payers should demand that patient preferences be considered, and that patients be provided the help they need to make decisions, according to John L. Fox, MD, MHA. Payers do not want to be interposed between patients and providers. Patients, Fox said, should be “afforded the opportunity to make their choices known and to have their choices respected.”
Ira Klein, MD, MBA, FACP, said that most cancer patients do not fully understand their prognosis or their treatment options. Patients, he said, “should have access to a little bit more understanding about what is going to happen to them from the beginning, the middle, and the end—whether it’s incurable disease, long-term survivorship, or mid-term remission.”
Fox cited examples in which patients were unaware of their prognoses. One study showed that 81% of patients receiving chemotherapy for incurable metastatic colorectal cancer thought that they were getting curative chemotherapy. Another study found that 69% of patients who had incurable metastatic non-small cell lung cancer thought they were getting curative chemotherapy. When patients are fully informed, they “tend to be less aggressive than their physicians” regarding their care.
A. Mark Fendrick, MD, said that the topic is not really about saying “no” but about shifting the discussion and altering the reimbursement to reflect the value of the treatment. In what he referred to as “nuance care,” the greater the treatment value, the lower the cost should be. For example, if the cure rate is 90% with a given agent, it should cost the patient less than if the patient stands to extend his or her life by a few months.
Cliff Goodman, PhD, posted a question to the panel: “How equipped are oncologists to actually listen to what the patient said—if it’s a ‘no,’ for example— and proceed accordingly?”
Fox pointed out that oncologists say they want to talk to their patients and want to know their goals of care and their preferences, but they don’t have good systems in place to have this conversation.
Some organizations are beginning to “create systems of care within practices so it becomes the routine.” Fox added that the time spent should be billable. “We can’t say this has value and then not reward that behavior.” His organization has a billable code for “advanced care planning,” he said.
Klein noted that, on the provider side, his organization has “pay-forvalue” arrangements with physicians so that they are encouraged to look beyond simply following the standard of care for each patient. On the patient side, “We’re looking at ways to have patients be more engaged (and) not be a passenger in the journey. That’s really hard to do.”
Goodman asked the panel to comment on the impact of healthcare reform on patient decision making. Klein said that reform within the context of an already fragmented system may have negative consequences. “You will have changing networks, changing copayments, changing coinsurances,” he said. “If people don’t have a way to make their way through the system and
understand what they’re going to pay, what they’re paying for, it will be a degradation in the care that we have today.”
“We need to remove any barriers that exist to ensuring that patients have an opportunity to express their goals of care,” Fox insisted. “Ultimately, we’ll drive down the cost of care if the evidence is correct, if we are more in tune with what the patients want, and we create systems of care that ensure that those voices are heard.”
Fendrick stated that the Affordable Care Act (ACA) has provisions that ensure that certain cancer screenings, such as mammograms for women over the age of 40 years, are available at no cost to patients. “The main issue is that most benefit designs in public and private plans basically have a one-size-fits-all system; all doctor visits cost the same; all drugs in the tier of the formulary cost the same; (and) every diagnostic test costs the patients the same out of pocket.”
Fox said that one of the challenges with nuance care is that it would be difficult to explain to people and also to implement. “There may be drugs that are more effective in one cancer versus another, and yet for us to be able to say, for one indication you’re going to pay more, in another indication you’re going to pay less, would be challenging.” EBO