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Drug cost debate must not detract from focus on value in cancer care
We are all at various stages of readiness for the transition from volume-based to value-based care.
The development of value-based care models is a major priority for most health systems, including the one in which I work. Our system has placed value front and center in its strategic planning and, among many initiatives, has created a team of chief value officers to lead and coordinate our efforts to improve value across departments and service lines.
Like most other systems, we are working hard to understand costs, improve quality, and develop more effective and accessible methods to monitor and improve outcomes. In parallel with these initiatives, we are exploring the best ways to deliver value-based care to our patients with cancer.
John Sweetenham
So far, this has been challenging, and we have been looking to best practices from other institutions and organizations to help us develop our metrics and our plans for improvement.
Costs vs. value
Organizations such as ASCO have taken a lead on incorporating value into the care of patients with cancer, giving the subject significant attention at its recent annual meeting in Chicago. On my way back from the meeting, I have reflected on how much I have learned — and also on how easy it is for attention to be deflected away from value and directed toward cost. Of course, the two are closely related, but they are distinct.
The simplest and most frequently quoted distinction between cost and value comes from Warren Buffett: “Cost is what you pay, value is what you get.”
No one would argue with that. In the health care environment, the definition of value has not been consistent, although it is typically characterized as a function of quality, service and outcomes and cost.
Michael E. Porter, PhD, a professor at Harvard Business School and acknowledged leader in value in health care, spoke at this year’s ASCO Annual Meeting.
He has proposed organizational structures most likely to deliver high-value care, centered on Integrated Practice Units (IPUs). These units would provide disease-focused care across multiple geographic venues, using established care pathways and consistent and accurate outcomes measurements. They would measure costs for every patient, be based on bundled payments for cycles of care, and be supported by a robust informatics infrastructure to collect the necessary cost, quality and outcomes data.
The IPU model is patient centered, and patient-reported outcomes are an intrinsic component. In many respects, cancer centers already follow this model and are well-positioned to embrace the IPU concept.
Despite this, I have the feeling that we are in danger of lagging behind other specialties in the quest to develop reliable metrics for value — and to apply them.
Of course, cancer care is complex, and it is much more challenging for us to identify cost, quality and outcome metrics than for some other specialties, particularly those that are procedure-based, where costs and clinical endpoints are somewhat easier to define. In this situation, the low-hanging fruit is drug costs. As most readers will be aware, much attention has been addressed toward the high costs of cancer drugs — a subject that raised substantial controversy at the ASH Annual Meeting in December and again at ASCO.
I sat in several presentations at which speakers ostensibly addressed “value” as a part of their talks when, in fact, they really only discussed the costs of treatment.
Just to be clear, I am not taking a position on the cost of anti-cancer drugs. I don’t have enough understanding of this subject to know whether the claims some physicians are making about drug pricing are accurate or not. I do agree that if one looks at costs of drugs in isolation, it’s difficult to escape the conclusion made by many that the current pricing structure is unsustainable.
But drug costs are not the whole story. My concern is that the tendency to focus on cost rather than value is not only missing the point (remember, value is what you get — if an expensive drug demonstrates improved activity, and also reduces relapse and the need for subsequent therapies, the value starts to look better) but runs the risk of deflecting attention from areas of urgent need for improving value for our patients.
Quality and outcomes
Equally important to the need to measure and improve value are accurate and reliable systems for measuring quality and outcomes. The development of guidelines and care pathways in oncology is now advancing rapidly. Multiple clinical decision support tools are becoming available to reduce variability in practice, and these are gaining widespread use. A growing number of software companies are moving into this space, offering products that assist with decision support, pathway adherence and quality.
These companies also offer the ability to collect and report quality metrics. The oncology community seems to be slow to reach consensus on which metrics should be primary indicators of quality, although the ASCO Quality Oncology Practice Initiative (QOPI) has widespread, if not universal, acceptance as a system for benchmarking quality in cancer.
Where we seem to be most in need of a consistent framework for benchmarking value is with respect to outcomes.
Nationally, there are few recognized, widely accepted outcome measures for specific cancer subtypes. Most cancer centers that publish their outcomes do so primarily as a marketing rather than benchmarking exercise, and cross-center comparisons are fraught with confounding variables, mostly related to case mix.
This is surely an area in which one of our national cancer organizations could take the lead, developing approved, evidence-based outcome metrics. The information technology to support reporting of these metrics already is available.
I congratulate ASH, ASCO and other organizations that have started to prioritize the value agenda — our patients deserve no less than to have this issue on the front burner. Among the many challenges ahead, let’s hope we can stay focused on value and not have the agenda hijacked by drawing all of the attention to drug costs. It is much more complex than that, and to suggest otherwise will threaten our ability to respond to the urgent need for value in cancer care.
Reference:
Porter ME and Lee TH. The strategy that will fix health care. 2013. Harv Bus Rev. Available at: hbr.org/2013/10/the-strategy-that-will-fix-health-care. Accessed on June 9, 2015.
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John Sweetenham, MD, is HemOnc Today’s Chief Medical Editor for Hematology. He also is senior director of clinical affairs and executive medical director at Huntsman Cancer Institute at the University of Utah. He can be reached at john.sweetenham@hci.utah.edu.