William J. Gradishar, MD, and Joyce A. O’Shaughnessy, MD, share their thoughts on how the providers identify value-based care.
Bruce Feinberg, DO: I’ll shift to the provider perspective because classically, the perception has been that providers are focused on the balance of efficacy and toxicity. With the advent of ACOs [accountable care organizations] and the OCM, the Oncology Care Model, there’s been this pushback—more inclusive of patient perspectives—that it should be patient-centric models, the notion of shared decision-making. I’ve also heard a lot of pushback from providers that it’s great in concept, but the reality is that health literacy in this country is quite poor. It’s considered to be only a third of the population is actually high health literate from different public health study estimates. Health literacy is not just comprehension and reading; it’s numeracy. It’s also more about understanding the data and the way the data are used. I’m curious, as we look at that patient perspective, how do you view the incorporation of patient perspective and the shared decision-making as you approach patient care in a value-based environment?
William J. Gradishar, MD: That’s a critical element obviously, and I suspect Joyce, in many ways, thinks the same. When we see any patient in the metastatic disease setting, our first thought may be what’s the most effective therapy as we start making and gauging our decision-making. That alone is not what decides what we’re going to recommend to the patient, but it’s where we start. Then that is tempered by looking at the patient and thinking about the adverse effects that are associated with any given choice of therapy. The point being that in any patient, you may know what the most effective therapy is, but it may not be. And when I say effective, I’m talking about clinical efficacy end points. But for a given patient, you have to look at them and talk to them. You have to decide what their overall medical condition is. As was pointed out by Kelli, different patients have different goals and what they’re willing to tolerate. All this is colored by what you pointed out: Patients have different levels of understanding regarding what we mean by clinical efficacy, what we mean by survival or time until you need your next treatment decision. People interpret that in very different ways. We always have engaged the patient to come up with a treatment recommendation that’s right for them, and it’s different. The same circumstances, the same clinical situation, and 3 patients sitting side by side, but the decisions might be somewhat different among those patients when you take all those variables into account.
Bruce Feinberg, DO: Joyce, anything to add?
Joyce A. O’Shaughnessy, MD: No, it’s a very nice conversation. I think I totally agree with Bill. There’s a lot of back-and-forth dialogue along the way. Considerations of access to medications is very important. The co-pays make a lot of our oral medications prohibitive often. Sometimes the pharmaceutical companies have access programs if the agent is fairly new and is being actively promoted, etc. But of our generic drugs, 1 that’s challenging frequently is capecitabine. It’s an excellent drug, but the co-pays can be prohibitive. We sometimes are limited in our ability to use it because we have to go to philanthropic foundational programs, and we have people in our practices for whom we have to cover the cost so these people can access medications. Sometimes philanthropic organizations have co-pay assistance for the patients, and sometimes their coffers run dry and we have to wait until the next time they get a bolus of money in there. There are very practical considerations about what we can access for patients. Just so you know, the whole value is an ongoing dialogue with our patients over time. Women will say, —or men; I take care of a few men with breast cancer too— “Hey, isn’t it time for a PET [positron emission tomography] scan?” I’ll say, “Well, we don’t really need a PET scan.” It would be, “OK, your tumor markers are fantastic, we know that they’re informative, and you’re doing fine.” I don’t think we need that PET scan. We dialogue about that. There are a lot of issues around value and access to care these days.