High chemotherapy costs are only one reason for the rising cost of cancer care. End-of-life care and hospitalizations are within an oncologist's control and must be better managed given new reimbursement structures.
If oncologists are to bring innovative treatments to the patients who most need them, they must confront their own role in escalating costs—and take ownership of the solutions, said a leading oncologist who has worn the hat of payer and technology leader.
“If oncology is going to get fixed, oncologists need to fix it,” said Michael Kolodziej, MD, the vice president and chief innovation officer at ADVI, who has worked recently for Flatiron Health and spent 3 years at Aetna. Kolodziej was the keynote speaker who concluded the first day of Patient-Centered Oncology Care®, the annual meeting that brings together stakeholders across cancer care, presented by The American Journal of Managed Care®.
Is the cost of cancer drugs a problem? Of course, Kolodziej said. But the decisions oncologists make are a big reason that US cancer care costs are on track to rise 27% to 157.77 billion by 2020 from where they were in 2010.
Speaking at the Loews Philadelphia Hotel, Kolodziej pointed to 3 pressure points: the cost of chemotherapy, poor end-of-life care, and unnecessary hospitalizations and emergency department visits. Oncologists can do more to impact all 3 using patient-centered medical homes, by embracing clinical care pathways, and by encouraging better palliative care and better end-of-life care.
For all the innovation in cancer care, oncologists have hit a crossroads. He showed a photo of the gas lines in the 1970s and likened oncologists to the Detroit auto industry of that era: Refusing to change is not an option, Kolodziej said.
He then featured a sample of Kymriah, the first approved chimeric antigen receptor (CAR) T-cell receptor therapy, developed just a few blocks from the meeting site at Penn Medicine. For pediatric patients with acute lymphoblastic leukemia (ALL), “this is transformative,” Kolodziej said.
In the old way of thinking, “The doctor might say, ‘Why don’t I just give it everybody with ALL?’ It’s not that the doctor is wrong. It’s just that the game has changed.”
Kolodziej understands this thought process. “We come from a time when we had so few therapeutic choices and were willing to try anything.”
But today, oncologists have many choices. And that’s part of the problem. Unnecessary variation helps drive up costs, and that has led to the rise of clinical pathways to guide care based on the best evidence available.
For oncologists who don’t like pathways, Kolodziej was blunt: quit complaining.
And while they’re at it, he said. “Stop complaining about pharmaceutical companies that are just trying to get a return on their investment.”
Embracing change, he said, will give oncologists the ability to connect the right patients with CAR T-cell therapy even though, “it costs more than most of your houses.”
Team-based care, early use of palliative care, and better use of end-of-life care not only reduce hospitalization and save money, but all lead to better experiences for patients, Kolodziej said.
For all the advances in cancer care, there are some patients who are not going to be cured and oncologists need to instead help these patients manage their disease to have the best quality of life for as long as possible. This may mean different conservations than oncologists have had in the past. While patients typically won’t bring up end-of-life care when they are first diagnosed with cancer, they know what they don’t want.
About one-third of cancer patients spend time in the intensive care unit (ICU) at the end of life. While oncologists might be unsure about what patients want, Kolodziej said, “None of them said, 'I’d really like to spend time in the ICU before I die.'”
Kolodziej then reviewed evidence from the COME HOME project and other efforts to reduce costs, and noted evidence from the University of Alabama Birmingham that found pairing patients with lay navigators dramatically reduced costs.
Some oncologists might not like pathways or medical homes, or be reluctant to promote good end-of-life care, but the arrival of changing reimbursement structures and Medicare’s Oncology Care Model will compel change. “Every one of these practices is going to be doing this math,” he said.