Influence of Value Frameworks in Clinical Practice
Joseph Alvarnas, MD: Understanding, in light of what you’ve all said, that cancer care is multidimensional and value is multidimensional, have value frameworks—such as those developed by the American Society of Clinical Oncology (ASCO), the National Comprehensive Cancer Network (NCCN), or the Institute for Clinical and Economic Review (ICER)—been adopted into practice in a way that you think changes the industry? And if so, how do you think they influence patient care? Bob, do you think we’re getting to more patient-centered care through these frameworks?
Robert Carlson, MD: I think the frameworks have different goals and different purposes. ICER is a framework that is really designed to understand what optimal drug pricing should be. And that really faces the payer community, the pharmaceutical industry, and the device industry rather than the patients and physicians. The ASCO Value Framework and the NCCN Evidence Blocks are really designed to focus on the physicians and the patients. The ASCO system is not yet, to my understanding, utilized in clinics, although ASCO is developing computer-based systems to allow that to happen. In terms of the NCCN Evidence Blocks, we currently have 33 guidelines with evidence blocks associated with them. We have limited that to the professional guidelines because we want the physician community to become comfortable with them before it’s expanded to patients so that—when a patient comes in and asks about them—the physician knows what they’re talking about.
But we are also working with patient advocacy groups because we also need tools that are patient centric and optimally developed by patients that can interface with the professional tools and are value-oriented tools. Because both the professional audience and the patient audience have very different needs in terms of what a value tool looks like. They should come up with, optimally or ultimately, the same sort of spectrum of options, but how we get there is a very different process, and we need processes for getting to values that are meaningful to patients.
As an oncologist, survival is valuable to me. Avoidance of toxicity is valuable to me. If we go to the patient community and ask, “What is valuable to you?” you hear about things like free parking. You hear, “The most valuable thing to me is my personal relationship with my medical oncologist.” Those are the sorts of things that you hear about, and they’re not necessarily mutually exclusive, but there’s a hugely different emphasis on the types of things that are sought.
John Fox, MD: I think these tools are on version 1.0 or 1.1 right now. I think the ASCO Value Framework has recognition, or values, treatment-free intervals, and patient-reported outcomes. Although, interestingly, I think it was FARYDAK (panobinostat), which is used to treat multiple myeloma, that got points because it was so toxic that patients had to stop taking it—and so they got a treatment-free interval. So, there are some nuances to that. I don’t think the NCCN Evidence Blocks take into account any of those things today, but I think they’ll continue to evolve. I think the challenge from the payer vantage point right now—I use them. I look at them frequently, more to assess whether or not the decisions that we’re making as a health plan are concordant or discordant with the evidence blocks or the value frameworks. But I think we’re probably a long way from using those as a fundamental element or an integral element of formulary decision making today.