My Struggle to Understand the Many Definitions of Value

Burt Zweigenhaft, BS

September 2015, Vol 6, No 8 - From the Editor

I believe that the dialogue and thoughts being shared and expressed by all cancer care stakeholders is exactly what we need today. Frankly, the conversation has been underground far too long, but the headlines today have been focused solely on the drug cost. Anyone thinking that cancer care costs are going to go down, simply doesn’t understand healthcare economics, because the cost to society will continue to go up over time, with true innovation and value delivered.

There are so many voices and new ideas emerging in redefining the value proposition in cancer care. We have to remind ourselves that cancer care is delivered by complex ecosystems of multidisciplinary care providers as treatment modalities and clinical pathways evolve, with experience, knowledge, and innovation. The value that society puts on this innovation when determined by free markets, underwrites what that market is willing to pay—period. We have seen this market interact when Peter B. Bach, MD, MAPP, of Memorial Sloan Kettering Cancer Center (MSKCC), NY, announced in an editorial appearing in the New York Times that MSKCC would no longer prescribe ziv-aflibercept (Zaltrap) to its patients with advanced colorectal cancer, because the innovator drug cost more than twice as much as monthly standard-of-care treatment with bevaciz­umab (Avastin), while providing the same survival benefit to patients. This is the free market at work.

We also now have the American Society of Clinical Oncology putting out guidance on their own value initiative in July; the soon-to-be-released (in October) National Comprehensive Cancer Network’s position statement on their definition of value; along with a payer perspective, such as of Anthem, with their Cancer Care Quality Program, and the Center for Medicare and Medicaid Innovation demonstration project. So, as you can see, the healthcare marketplace will find solutions—the good solutions will last, and the flawed ones will go away.

What cancer care providers must remember is that their patients and their families own part of this very personal decision about their cancer care, and their definition of value is unique to their particular situation. Therefore, whatever society and the healthcare industry agree on in the final current thinking definition of value, we must consider that the patient dynamics weigh heavily in that formula.

Finally, as an economist I strongly support unregulated economic interactions between providers (supply side) and utilizers (demand side). I believe there will be such market mechanisms, specifically free market–based systems, that will find the many different ways to measure and reward true innovation and the value received by stakeholders. At the end of the day, I trust it will be the healthcare stakeholders in the cancer care marketplace who will best determine the meaning of delivered value and hopefully not regulatory actions such as the ones we see in other countries.

Suggestions for Developing a New Gold Standard of Cancer Care

  • Replace traditional paradigms, and provide patients with customized, individualized combinations of drugs in partnership with patient groups and the leading pioneers
  • Transform everyday clinical care into patient-centered, N-of-1 approaches, given that each patient with cancer has a unique molecular profile; we need a new, patient centered, N-of-1 approach that utilizes individually tailored treatment
  • Promote changes in regulation and reimbursement to advance the development of tools to customize combination treatments
  • Increase public and patient advocacy awareness of the economic and social value of shifting from a drug-centric to a strategy-centric approach to treatment, with the goal of controlling cancer as a chronic disease.
I commend all healthcare stakeholders for bravely taking up the conversation and entering the “value debate,” because if we are to find the value-based solutions, all voices need to be heard. Like you, I intend to be one of the voices, as I, too, struggle to define value.