The Lynx Group

Site of Care Influences Value in Cancer Care

May 2012, Vol 3, No 3

At the Association for Value-Based Cancer Care (AVBCC) second annual meeting, Winston Wong, PharmD, expressed concerns that the site of delivery of cancer care affects efforts to rein in costs and provide value in cancer care. Wong expanded on this issue in the following interview.

AVBCC: Why do you believe that the site of delivery of cancer care can impact the attempt to rein in costs of cancer care and provide value?

Dr Wong: Here is why. When chemotherapy is delivered to a patient in the physician’s office, there are the cost of the drug, administrative costs, and the cost of ancillary services. Let’s say the total office visit, including the cost of chemotherapy, is $4000. You can take that exact same service and drug and deliver it at a large center, such as, in our area, Johns Hopkins, and the cost could be $6000 or even up to $8000. Essentially, it may double or even triple in cost, depending on the procedure, the service, and the drug that is prescribed.

AVBCC: Why is there such a large differential in cost?

Dr Wong: It is basically because the healthcare system cannot function without the large hospitals. They have market power and can negotiate better deals. At the end of the day, hospital billing will be at least twice that of a community practice, across the board.

AVBCC: Do large hospitals and cancer centers acknowledge this?

Dr Wong: Their comment to payers would be that they are tertiary care hospitals, and that their patient population is sicker, and to some degree that is true. Large hospitals may get more difficult cases, administer more expensive third-line therapies, and so forth. But comparing apples to apples, their costs are much higher than in community practices.

AVBCC: What can be done to bring more equity?

Dr Wong: On the oncology side, we have not been able to achieve more equity yet. The strategy that we at CareFirst are trying to employ initially with our Pathways Program is to reimburse at a higher rate to community practices. We may not necessarily be directing patients away from hospitals, but we are doing something to help maintain community oncology practices so that they are available to treat these patients. If there are fewer community practices, patients with cancer have less choices. The site-of-care issue will be driven by the viability of community practices. If we cannot help community oncologists stay in business, the site of care will not be an issue.

AVBCC: You have talked about the need to integrate primary care and to bring more value to oncology. Could you elaborate on this?

Dr Wong: Here is an example of the current state of things. My mother passed away in 2007. When she was diagnosed with cancer and was being treated with chemotherapy, she became neutropenic and ended up in the emergency department. The hospital contacted the primary care physician (PCP) on record, but he had no clue about her condition. Once an oncologist was taking care of her, there had been no communication with the PCP. And let’s look at survivorship. She may have to go back to the oncologist for some routine tests, but she may have an annual check-up the following week with her PCP, and he may order the same laboratory tests. This kind of overlap and duplication should be eliminated from the system.

AVBCC: How is CareFirst BlueCross BlueShield advancing this concept of more integrated care?

Dr Wong: With the primary care patient-centered medical home, we are trying to involve the PCP as the “quarterback of care,” as we say. Currently, when an individual is diagnosed with cancer and referred by his or her PCP to a specialist, the PCP usually severs ties with the patient. We are asking our PCPs to be more accountable and to follow these patients while they are under the care of specialists—oncologists or others—and maintain primary care as the patient’s home, but within an integrated process. Maybe 5 of 10 patients with cancer will ask their PCP to refer them to an oncologist, but the other 50% will choose an oncologist on the basis of favorable word of mouth. Or, they may want to go, for example, to MD Anderson, because of its reputation and not because they have seen scientific evidence that their care will be better or that community care is worse. We all pay more for that patient, with very little difference in quality of care or in outcomes compared with care in the community setting. We believe that the PCP can direct the patient more toward value-based cancer care. PCPs can help guide these referrals, and they can take care of the non–cancer-related conditions that patients with cancer will have. We want this care to be under the PCP, not the oncologist.

AVBCC: How are PCPs and oncologists accepting this model?

Dr Wong: We do not know yet—our program just started—but this is something we are interested in learning. We believe that it is in everyone’s best interest for patients to have a coordinator of care, and we think that the most important provider in this regard is the PCP. We think that PCPs and oncologists working together will become inevitable with the changing time. As the PCP becomes more involved, there will have to be more communication between them.

AVBCC: What progress is being made to bring this concept to fruition?

Dr Wong: There are many groups with their own small projects like ours, and none is known to be the best way to do this. I think that these will eventually merge into something that we will all use; however, we are still trying to get some accountability around these programs, and we are still very early in that game.

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