The transition to payment models in cancer care that reward quality might do more than save money. In some cases, the change might improve relationships between patients and oncologists. Whether this happens or not, there’s no denying that therapy costs are driving decisions in cancer care, both by patients and, in some unpleasant cases, by the institutions pledged to serve them. The economics of cancer care are playing out on the front lines, and they do affect outcomes, according to a panel moderated by Jan Berger, MD, MJ, editor-in-chief of The American Journal of Pharmacy Benefits.
The panel, featuring Ted Okon, MBA, executive director of the Community Oncology Alliance; Debra Patt, MD, MPH, of Texas Oncology; and Stacie Dusetzina, PhD, an epidemiologist from the University of North Carolina at Chapel Hill, covered “Perspectives on Economics and Outcomes of Community vs Hospital Oncology Practice.”
At the start, Berger observed that today’s movement toward measuring quality and building payment structures around quality metrics stands apart from past reform efforts in that it seeks to build on the best of prior models rather than discard everything and start over. To that end, she asked the panelists how current reforms might change patient-provider relationships, especially from the perspective of cancer treatment in a community practice compared with a hospital. Dusetzina, who has studied the impact of therapy cost on patients, said that the difference in setting can have a compelling effect on relationships. “Care costs more for everyone in hospital-affiliated clinics,” she said, due to facility charges. Getting that extra bill, she said, can negatively harm the relationship with the oncologist.
Okon expressed concern about the consolidation and “corporatization” of hospital-based care, especially with the expansion of the 340B drug pricing program. This initiative, run by the Health Resources and Services Administration, was set to allow “safety net” hospitals to obtain cancer drugs at deep discounts so those medications can be offered to vulnerable patient populations. However, he asserts that 340B has been allowed to expand far beyond its intended purpose, at the expense of community practices unable to obtain drug discounts. The situation, he said, is forcing the closure or consolidation of community oncology practices, leaving some remote areas without coverage, and “is unsustainable.”
Okon said he hears “horror stories” of patients being asked to sign waivers agreeing to cover drug costs for off-label uses at prices well above what the hospital would have paid. “The bottom line is, this is really bad medicine,” he said. This corporate culture in hospital-based cancer care, he said, is coming “in an era when we’re thinking more about quality, when we’re thinking more about value and more about measurement for the first time.”
“There’s no question,” said Patt, that oncology care needs a transition from current incentives to a “more population-based model.” Her theme throughout the panel discussion was the need for oncology practices to embrace a team-based approach, one that does not require all information to flow from the oncologist, but instead distributes care and decision making among several professionals, including social workers, nurse practitioners, care coordinators, and even psychologists. But Patt acknowledged this is hard on a community practice. “This requires infrastructure investments. Most oncology clinics have small margins by which they derive revenue. For each incremental investment you make, you have to demonstrate return,” she said.
Without reimbursement reform that rewards practices for a team-based approach, hospitals alone might find it easier to make these investments. And yet, Patt said, she sees more innovation happening at the community level because it comes from practice culture and is not seen as a directive from the hospital administration. She would be concerned if an oncology home model became just a set of metrics for a practice to follow. “Then you’re not really changing how you’re delivering care,” she said.
But change has to come, and community oncology practices do, as a group, deliver care at a lower cost than hospitals and academic centers. “The cost issue is real,” Patt said. “I’ve had patients say, ‘I can’t pay for that oral chemotherapy for my renal cell carcinoma. I’ve decided it’s in the best interest for my family for me to die.’”
Berger than asked the panel to address some of the tougher issues in oncology care today: how to educate patients and providers on when palliative care might be best and how to deal with transparency issues, so that “doing less” does not come across as “withholding care.” Change in healthcare is never easy, Patt said. “There is always the ‘New York Times’ test,” she said. For some audiences, any mention of palliative care will come across as a “death panel” conversation. “Nothing like cancer pulls more at your heart strings…society is very polarized about it.” That reality, she said, means it’s the oncology community’s job to change how people think about cancer care. For some today, it can become a chronic disease, “but many people do die of cancer.”
Okon agreed that education is very much needed, but also among providers: both on what he called the “macro level,” about the business of cancer care, and on the “micro level,” about issues such as end-of-life planning. Dusetzina said one of the barriers to having good conversations with patients about their options is the lack of understanding about the associated risks.
The average person equates high cost with high value, she said, and doesn’t grasp that when an insurer might want to withhold an expensive therapy, it’s because of evidence it won’t work, “not because it’s expensive and the insurer doesn’t want to pay for it.” The panelists agreed that the oncology medical home model, with a team-based approach, should be the wave of the future.
Okon said change must start with the oncologist, who must abandon the “queen bee” model of being the only decision maker, because it’s too inefficient. “They have to change their mind-set,” he said.