IOM Cites Looming Cancer Care Crisis, Recommends Course-Correcting Strategies

Charles Bankhead

October 2013, Vol 4, No 8 - Economics of Cancer Care

An evolving crisis in cancer care will reach a critical mass over the next 15 to 20 years without a transition to a more patient-centered, evidence-based delivery system, warn the authors of a report from the Institute of Medicine (IOM).

A conflagration of factors will stretch cancer care to the breaking point, including the rapidly aging patient population, a growing case volume that will overwhelm the oncology workforce, and the rising cost of care. The 315-page report, “Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis,” enumerates a laundry list of reasons for the crisis but also offers suggestions for improving cancer care and avoiding a socioeconomic and professional meltdown.

“As a nation, we need to chart a new course for cancer care,” said Patricia A. Ganz, MD, Distinguished University Professor of Medicine and Public Health, University of California, Los Angeles, and Chair of the committee that wrote the IOM report. “Changes are needed across the board, from how we communicate with patients, to how we translate research into practice, to how we coordinate care and measure its quality.”

The report identifies key stressors that will meld into a crisis. The number of adults aged ≥65 years, which is the fastest growing segment of the US population, is expected to double between 2010 and 2030. This population will account for the most new cancer diagnoses, which are projected to increase by 45% by 2030, from 1.6 million to 2.3 million annually.

Growing Caseload and Treatment Complexity
Oncology providers will be unable to keep pace with the growing case- load, because training programs lack the capacity that the rapid expansion requires to meet the growing demand for cancer care. A study commissioned by the American Society of Clinical Oncology (ASCO) found that the oncology workforce will have 2500 to 4100 fewer oncologists than needed to keep pace with the demand for services by the start of the next decade.

Advances in the understanding of the molecular and cellular biology of cancer have led to increased awareness of the complexity of cancer and cancer therapy, frequently resulting in the development of new therapies that address abnormalities and genetic mutations in small subsets of patients. Clinicians are often challenged to remain abreast of these developments, or to formulate therapeutic strategies that incorporate the rapidly expanding knowledge base. As a consequence, de­­cisions about cancer care are often not sufficiently evidence-based, according to the IOM.

The IOM committee found that only a minority of clinicians involved in cancer care follow ASCO and other professional organizations’ guideline recommendations. The reasons for nonadherence fell into 3 general categories—some physicians believe that their experience is more valuable than guidelines in clinical decision-making, others think their patients differ from those covered by the guidelines, and still others are unaware of the guidelines’ recommendations.

The IOM committee also found clinicians’ performance lacking in some specific areas. For example, a substantial proportion of oncologists demonstrated a lack of proficiency in the use of palliative care when the therapeutic options for a patient have been exhausted.

Communication with patients is another area for improvement. Too often, clinicians do not discuss with patients the advantages and disadvantages of different or competing treatment options. In many instances, clinicians do not explain the goals of treatment or how a particular type of treatment may affect a patient’s quality of life. The IOM committee also identified several recent studies showing that 65% to 80% of patients with poor prognoses erroneously believed that they had a curable condition, indicating providers’ discomfort with delivering bad news.

Burgeoning Costs a Key Stressor
The burgeoning cost of cancer care constitutes another key stressor in the crisis framework. According to Dr Ganz and colleagues, the cost of cancer care has risen faster than that of other areas of medicine. The estimated total cost of cancer care increased from $72 billion in 2004 to $125 billion in 2010, and is expected to increase by another 39% by the year 2030, reaching an estimated total annual cost of $173 billion. Further adding to the stress are the ongoing financial struggles of Medicare, the largest single healthcare insurer for people aged ≥65 years.

Despite identifying several shortcomings in oncologists’ performance, Dr Ganz emphasized that the reason for the approaching crisis is multifactorial. “Most clinicians caring for cancer patients are trying to provide optimal care, but they’re finding it increasingly difficult because of a range of barriers,” she said.

Future Strategies
The committee identified 6 focal areas for the development of evidence-based strategies to address the stressors pushing cancer care toward a state of crisis and to improve the delivery and control the cost of care. Listed by priority, the areas are:

  • Support for informed decision-making. Multidisciplinary cancer care teams should engage patients and families and provide understandable information about the patient’s prognosis and the benefits, potential harms, and costs of treatment. The goal should be to guide patients toward decisions that are consistent with their needs, values, and preferences
  • Development of an adequately staffed, trained, and coordinated workforce. New models of team-based care are encouraged to promote care coordination and to address challenges and stressors identified in the study. High-quality cancer care requires a workforce with an adequate number of clinicians who have appropriate training in core competencies
  • Evidence-based cancer care. Too many medical decisions lack evidentiary support. Moving forward, clinical research should include efforts to accumulate the evidence that patients and clinical care teams need to make informed decisions about treatment
  • Intelligent information technology systems. High-quality cancer care requires information technology systems that “learn” from real-time analysis of data on patients with cancer in a variety of care settings
  • Translation of evidence into clinical practice and quality assessment and improvement. Clinicians should have ready access to evi­dence-based tools and initiatives that can be incorporated into clinical practice, quality assessment, and performance improvement
  • Access to affordable cancer care. The committee called on the US Department of Health & Human Services to develop a national strategy that leverages existing community interventions to address disparities in cancer care and provide accessible and affordable cancer care.

Value-Based Care, New Reimbursement Models
The overall objective is to improve the affordability of cancer care through the restructuring of the payment system and the elimination of waste. Professional organizations should rapidly and publicly disseminate evidence-based information about valuable cancer care practices, as well as practices that are unnecessary or that may involve more harm than benefits.

Payers need to develop their payment policies based on the evidence-based conclusions of these organizations. New models of reimbursement should be developed to offer cancer care teams the incentive to provide evidence-based care that is also in alignment with patients’ needs, values, and preferences. If assessments of specific reimbursement models show increased quality and value, payers should quickly move away from the traditional fee-for-service model to the newer payment model.

The study and report were sponsored by the National Cancer Institute and the Centers for Disease Control and Prevention in collaboration with multiple professional and nonprofit organizations devoted to cancer care.