AVBCC 5th Conference: Continuing Challenges for Optimizing Value in Oncology
Washington, DC—The Fifth Annual Conference of the Association for Value-Based Cancer Care (AVBCC), held May 3-6, 2015, launched 3 days of presentations by US oncology stakeholders, including physicians, pharmacists, nurses, payers, policymakers, and drug/diagnostics manufacturers.
Co-Chairs Burt Zweigenhaft, BS, President and Chief Executive Officer of Onco360, Louisville, KY, and Gary M. Owens, MD, President of Gary Owens Associates, Ocean View, DE, introduced the current trends and challenges in optimizing value in cancer care. The goal of the conference was to articulate challenges and potential multistakeholder solutions to the barriers associated with cost, quality, and access to care.
Cost pressures and payment models continue to dominate the conversation, said Mr Zweigenhaft. From the perspective of the medical oncologist, infused drugs remain the largest portion of drug utilization spending. Drug margins no longer drive practice incomes, he said.
Oncology drug margin compression continues following the 2013 budget sequester, which reduced providers’ reimbursement by almost 30%. The large drug margins have given way to smaller margins and to larger administration fees, resulting in higher overall practice costs.
Some consequences of the fiscal unsustainability in oncology are more common prior authorizations, higher deductibles, tiered formularies, bundled payments, and new pathways. The increased complexity that these measures create, along with declining margins, have “made it really tough for most of these practices to find fiscal sustainability,” Mr Zweigenhaft said.
A shortage of oncologists will also transform care. Most of the 11,000 oncologists who are treating patients with cancer are aging. The number of oncologists aged ?65 years now exceeds those aged ?40 years, and older physicians carry a heavier clinical workload, according to the 2015 report, The State of Cancer Care in America, from the American Society of Clinical Oncology.
Oncology pharmacists and nurse navigators will have to step up to fill the need, Mr Zweigenhaft said, helping patients to reconcile their treatment goals and manage their toxicities, including financial toxicity.
The challenges with new payment models in oncology also include the question of the affordability of personalized medicine. “Genetics will move us from upwards of 600 diagnoses to 1200 individual diagnoses of cancer,” said Mr Zweigenhaft. The significant growth in molecular diagnostics, including the FDA’s approval of companion diagnostics, creates an enhanced role for information technology, as health systems and payers attempt to tackle the abundance of new information in cancer care.
The 340B Drug Pricing Program has created a perverse financial incentive for hospitals that qualify for 340B to buy physician practices, generating more revenue per patient. Patient engagement is needed to improve patient adherence as a way to enhance economic and clinical outcomes. Citing the example of imatinib (Gleevec) in the treatment of chronic myelogenous leukemia, adherence to therapy improved outcomes for all stakeholders, including the patient. “Low-compliance patients represent a higher global spending,” Mr Zweigenhaft noted.
Defining Value in Cancer Care
Dr Owens summarized the discussion of the Steering Committee, which attempted to define issues in value-based care in oncology. He listed 8 key points, including issues relevant in the formula for value. These issues included the need for patient-reported outcomes. He questioned, “What happens in the real world after these drugs get in common use?” Other concerns included the failure to tackle the total cost of care and toxicity in cost to multiple stakeholders, including to patients and their families.
As one of the solutions, the assumption of risk across various stakeholders (eg, hospitals, payers, providers, drug manufacturers) “may eventually help us manage these financial toxicity issues,” Dr Owens suggested. “All of us who are in healthcare financing have a fiduciary duty, whether you’re an employer, payer, a provider, or a drug developer. Everybody has a clear understanding of what their fiduciary roles are and in defining those fiduciary roles.”
As the use of electronic medical records and large databases in the insurance world grows, it is from these sources that information will be developed. “It’s a huge step in translating those data into information, and I think we’re still taking the baby steps right now,” noted Dr Owens. “The more you can know about a disease process and the more you can know about the different interventions and what the outcomes are, hopefully the better you can manage it.”
He also advised that a common language is needed to align incentives. Finally, Dr Owens pointed out that the failure to provide timely care, provide state-of-the-art care, or to advise patients of the potential downsides of treatments can result in litigation risk.