Optimal Care for Patients with Cancer: Who Decides?
Hollywood, FL—Cancer care today is influenced by an ever-broadening array of players, and what was once an intimate relationship between patient and physician now involves multiple decision makers. At the 2012 National Comprehensive Cancer Network (NCCN) meeting, a panel of various stakeholder groups addressed the questions of what and who defines “optimal care” for today’s patient. Moderator Clifford Goodman, PhD, Senior Vice President at the Lewin Group, Falls Church, VA, summarized the panel’s observations: “The locus of decisions that we call the ‘crucible’ has changed. It’s not just the clinicians, patient, and family; it extends much further. Whether you think literally or figuratively, other actors are in that room. The content for decision-making now ranges from the small exam room all the way to Congress.”
The Need to Define and Measure Quality
Quality care has yet to be fully defined, but to Sheri Ling, MD, Deputy Chief Medical Officer for the Centers for Medicare & Medicaid Services (CMS), it means care that is safe, well-coordinated, and centered around patients and their families. Evidence of good outcomes is also important, and the delivery of care should be monitored through structured systems that are beginning to emerge, Dr Ling said.
The issue of quality permeates the entire cancer journey, according to Karen Alban, RN, OCN, of the Carroll Regional Cancer Center in Westminster, MD. “Cancer care decisions are not a one and done proposition,” she said. Furthermore, end-of-life care should be an important part of the care planning, because it greatly affects quality of life, as well as the economic bottom line. Although hospice is handling these patients well, too few patients die there. The problem, she noted, is that these conversations occur too late in the game. “We need to do better at moving palliative care into the continuum sooner,” Ms Alban suggested.
Al B. Benson, III, MD, FACP, past president of the NCCN, and Professor of Medicine, Northwestern University, Chicago, IL, said that the “first encounter sets the tone for what happens in making decisions over time.” This is the time to “recognize who is in the decision-making arena” and to offer patients guidance, not just for their cancer treatment, but for wellness, psychological issues, financial concerns, and all the rest.
David Pfister, MD, an oncologist at Memorial Sloan-Kettering Cancer Center and Professor of Medicine at Weill Cornell Medical School, NY, noted that treatment options are rapidly expanding, and this increasingly requires multidisciplinary planning. He applauded the emergence of new metrics to help guide physicians and patients in making choices.
However, Ray Lynch, MBA, Executive Director of Huntsman Cancer Hospital, Salt Lake City, UT, said that multiple options also enhance the complexity of care, and that “crawling through the data is a challenge.” Rural oncology practices that lack other specialists in the area may have trouble meeting the demand for comprehensive cancer care, Mr Lynch said.
Cost Affecting Treatment Options: Who Pays for What?
It is clear that payers have become integral to the decision-making process, and the patient’s financial reality is a component of modern cancer care, the panelists maintained. As Mr Lynch noted, “What we do in the inner circle is conditioned on who is going to pay for what.”
Nancy Davenport-Ennis, Chief Executive Officer of the National Patient Advocate Foundation, agreed. “The payer plays a role through the benefits that are offered” by the health plan, she said. “Treatment protocols are often impacted by the insurance product,” especially when out-of-pocket expenses are high. Although 15 states have passed legislation that mandates parity in the payment structure between intravenous and oral agents, for states that have not, the disparity in drug costs clearly impacts decision-making, she said. “Discrete differences in reimbursement influence care.”
Lee N. Newcomer, MD, MHA, Senior Vice President of Oncology Services at United Healthcare, took some exception. Although fee-for-service still reigns, virtually any approved regimen will be reimbursed, at least by the major third-party payers, he said. When cancer is diagnosed, insurance premiums, copays, and deductibles more than pay for themselves, he maintained. “For a $3000 deductible, a person is going to get $120,000 worth of therapy for her disease. I would say that’s a pretty good deal,” Dr Newcomer commented.
Discussing the impact of payers on optimal care for patients with cancer, Scott Gottlieb, MD, a physician and resident fellow at American Enterprise Institute, said we need to look separately at the public and private marketplaces. “In the private sector, we are seeing consolidation of practices, hospitals acquiring practices, 340B programs, capitated arrangements, and so on. We are seeing more narrow network types of plans, and this is shifting power to the payers and hospitals for making more granular decisions, which have an impact on treatment choices,” he said. “In the government sector, you are seeing a similar move toward centralization of decision-making, but it is driven by different needs and political realities.”
“For instance, the CMS wants authority to make decisions about what should and should not be covered,” Dr Gottlieb said. Power to follow the “least costly alternative” policy, which would allow CMS to reimburse only for the lowest-cost interchangeable option, “may in the near future be conferred on CMS,” he observed.
Adherence to Guidelines Key to Quality and Value
Guidelines and pathways help providers understand the best use of diagnostic and treatment modalities in an increasingly complex era, said Dr Benson, and they should be part of training programs and tumor boards. Mr Lynch agreed, stating, “The closer we get to conforming to the NCCN guidelines, the more quality we can deliver.”
Dr Newcomer added, “Guidelines are advisory, with lots of value; they are as good for an individual as they are for a population,” and they can eliminate waste. “If we start to pay more attention to standardizing and becoming closer to those guidelines, a lot of the cost discussions will go away,” he predicted. Inconsistent use of guidelines is the current norm. United Healthcare, he said, was surprised to see a guideline adherence rate in the 60% range among 5 conscientious oncology groups. “For other oncologists not thinking about guidelines on a daily basis, the adherence rate is probably far less,” Dr Newcomer speculated.
But Dr Benson added that deviation from guidelines is often warranted, and that guidelines and pathways are intended to assist with decision-making. “A guideline is just that, not a prescription of care,” he stated.
Dr Newcomer acknowledged that physicians in his network can deviate from the guidelines when there is a medical reason, “and it is never a deviation from a pathway to go onto a clinical trial.”