Value Propositions in Oncology: The Physician Perspective
Chicago, IL—The rising costs of cancer drugs and medical services, along with increased copays and high deductibles for patients, are adding a serious financial hardship to patients diagnosed with cancer, according to Neal J. Meropol, MD, Associate Director, Clinical Programs, University Hospitals Seidman Cancer Center, Case Western Reserve University, Cleveland, OH.
At the value session during the 2015 American Society of Clinical Oncology meeting, Dr Meropol emphasized it is now more important than ever for oncologists to discuss value issues with their patients in relation to their treatment decisions.
“At the point of care, I don’t think oncologists are going to become gatekeepers in terms of cost,” he said. “However, we really do have the opportunity to become gatekeepers based on value in helping our patients choose between different therapies that may have the same cost but different value.”
Cost Impacts Adherence and Outcomes
In oncology, value has a direct impact on patient outcomes, influencing patient adherence to a potentially life-saving therapy. Patients who have to pay more are less likely to be adherent, Dr Meropol said.
“If they have a higher copay rather than a lower copay, there is a direct impact on outcomes,” he emphasized.
Escalating out-of-pocket expenses are contributing to disparities in care. Medicare patients with private supplemental insurance are more likely to receive indicated chemotherapy than those without this insurance, and 15% to 25% of patients report difficulty in paying for their cancer care, Dr Meropol said.
Because cancer is life-threatening, the prevailing concept is that patients would pay any cost for survival. According to Dr Meropol, however, recent empirical data dispel this myth.
“When we randomly varied the scenario presented to patients in terms of what the cost would be, in terms of potential benefit, and in terms of toxicity, we found that annual household income, and whether or not a patient was working, directly affected their stated preference for therapy,” he reported. “Patients who were out of work were more likely to favor low-cost therapy than patients with higher incomes.”
When surveyed across diseases, patients were also found to value quality of life and length of life relatively equally. Only a minority of patients stated a preference of length over quality, Dr Meropol indicated.
His solution begins with improved communication from physicians.
“Our patients want to discuss cost of care with us,” Dr Meropol said. “They want to know out-of-pocket costs before starting treatment, and in many cases, they would like their doctor to know how much they’re spending themselves on their cancer treatment.”
What Motivates Physicians?
Dr Meropol presented the physician perspective on whether providers are incentivized to provide more care or recommend therapies that are more expensive to their patients.
“There are empirical data demonstrating that when reimbursement for surgical procedures goes down, doctors perform more of these procedures to hit their targeted income. So physician behavior is clearly impacted by financial incentives,” he suggested.
Although these incentives should not be ignored, Dr Meropol believes that physicians are primarily driven by a desire to provide optimal care. For that reason, he stressed the importance of creating new payment models.
“We shouldn’t have an incentive to recommend treatment based on intensity of treatment or its cost,” he said. “We need to find a way to reimburse nonphysician ancillary services like patient navigation and patient education, so that practices can survive and thrive and provide the highest-quality care. We need to pay for care coordination and reward quality rather than the volume of services we provide.”
Dr Meropol listed the tools that he would love to have at the point of care.
“I’d like to know what the relative value of different treatment options is going to be,” he said. “I would love to have models and decision tools that would help me predict the benefits and toxicities for my individual patient….And I’d like to know, in real time, the anticipated out-of-pocket costs for my patients based on their insurance….In this way, I might help them make the best decision based on their understanding of the value of the treatment options.”