NCCN Panel Debates Cancer Care in Value-Based Healthcare Models

Wayne Kuznar

NCCN Annual Conference, Value in Oncology


Orlando, FL—The delivery of cancer care in value-based healthcare models was the subject of a roundtable discussion at the 2018 National Comprehensive Cancer Network (NCCN) conference. Panel members addressed the progress being made in achieving greater value in oncology care, the high costs that continue to burden patients, and the desire for access to comparative data. Clifford Goodman, PhD, Senior Vice President and Director, Center for Comparative Effectiveness Research, Lewin Group, Falls Church, VA, moderated the discussion.

Financial Burden Impedes Access

Financial toxicity has become a concern to oncologists, as patients are faced with large deductibles and copays and often seek alternatives to costly therapies, said Daniel P. Mirda, MD, President, Association of Northern California Oncologists, Napa. “Sometimes the best option is the most expensive option, and we have to look for second choices that are less expensive,” Dr Mirda told listeners. In this way, financial toxicity impedes access to the best care. Travis H. Bray, PhD, Executive Director, Hereditary Colon Cancer Foundation, Portland, OR, noted that 78% of cancer survivors report moderate to catastrophic financial burden “and that’s continuing to go up.” The for-profit system as it stands is aligned to generate value for the pharmaceutical industry, but not necessarily for patients, he said. Although guidelines for drug therapies are generally being followed by payers, those for cancer prevention are getting short shrift, Dr Bray said. Approximately 10% of cancers are preventable if genetic testing is conducted before cancer onset, but often the tests are delayed until after cancer develops.

Improving Value in a Cost-Conscious Market

An enhanced collaborative interaction between insurers and providers is driving value, suggested Bhuvana Sagar, MD, National Medical Director of Oncology, Cigna. These collaborations are leading to decreases in inpatient and emergency department utilization, and earlier use of palliative care; however, these improvements have been realized mostly in large provider groups. Smaller-volume providers tend to have higher costs because of increased volatility, “so we are trying to address that dynamic as well,” Dr Sagar said. She said that Cigna and other insurers are working to be able to track improvements in value and outcomes, but they are not there yet. “I don’t think we have enough clinical detail. Oncology is very complex; very heterogeneous,” she stated. Cigna conforms to NCCN guidelines in its clinical pathways and does not limit treatment options recommended by NCCN, but it would like providers to look at value when selecting therapy, Dr Sagar said. Much of the discussion of value is focused solely on cost, to the exclusion of the quality component of the value equation, said Randy Burkholder, Vice President of Policy and Research, Pharmaceutical Research and Manufacturers of America. “Our mission is to bring value to patients first and to the system overall. I think we have structures around value-based payment that are aligned around that,” he said. Mr Burkholder claimed that the system is delivering value in the form of better treatments and outcomes, and that financial hardship is a function of more than just cancer drugs costs; hospital costs, physician costs, and nonmedical transportation costs drive approximately 80% of the total cost of cancer care. Pharmaceutical companies deserve to profit from breakthrough medications that offer value, said Lee N. Newcomer, MD, MHA, Senior Vice President, Oncology and Genetics, UnitedHealthcare Group, but he bemoans the lack of a “free market” when it comes to pricing. Pharmaceutical companies are using incentives built into the system, so a shift to help generate optimal value may require a change in the system, he argued. In agreement was Ron Kline, MD, FAAP, Medical Officer, Patient Care Models Group, Centers for Medicare and Medicaid Services Innovation Center (CMMI). He pointed out large differences in pricing for drugs in the same class, with approximately the same effectiveness for the same form of cancer. A free market system would not tolerate such price discrepancies, Dr Kline said. Mr Burkholder countered that the market for cancer differs from that of many other diseases in that patients can respond to one treatment but then resistance develops and the patient requires other therapies in the same class for subsequent lines of treatment. Strong clinical pathways and utilization management tools developed by institutions and payers have generated cost-savings, he added.

Has the Oncology Care Model Driven Value Discussions?

The Oncology Care Model (OCM), which was developed by CMMI, encourages optimal treatment for patients, at a high value, said Dr Kline, adding that value may be different for individual patients. “We don’t tell physicians how to practice medicine. You decide as a physician what is best for your patient,” he said. Dr Kline believes that the OCM has driven value discussions. “The pharmaceutical reps used to come in and buy us lunch, and now they come in and tell us why their drug has a higher value than their competitor,” Dr Kline said. Cost factors, however, often are not apparent to oncologists who are treating the patients in front of them, he admitted. Dr Goodman asked how providers can make better value decisions without access to cost-effectiveness data, and without the expertise on the business side of caring for patients. “This does not sound like an optimal operating system,” Dr Goodman said. The Hawthorne effect (ie, a change in behavior in response to awareness of being observed) is real, said Michael N. Neuss, MD, PhD, Chief Medical Officer, Vanderbilt-Ingram Cancer Center, Nashville, TN. Physicians who are shown dollar amounts attached to their prescribing in relation to their peers will adjust their prescribing, he said. “It is very clear that that data is valuable,” Dr Mirda said. “We need more immediate data, but…we also have to be able to take care of that patient, and not have it driven completely by cost,” he added. One of the underappreciated aspects of the OCM is that OCM practices receive a quarterly report detailing their use of services and drugs, and how they compared with other OCM and non-OCM practices, said Mr Burkholder. The secretary of the Department of Health & Human Services has the authority to apply the model of the OCM at a national level, he said, depending on the demonstration project’s success at achieving quality. Lessons learned from the OCM would be diffused more rapidly into practice by incorporating the data into the electronic health record (EHR) system in the form of decision-support tools, Dr Newcomer postulated. When asked whether the data must be available in a timely fashion to support real-time decision-making, Dr Newcomer said that providers “don’t need real-time data to make that happen at the immediate point. It informs what you build in decision support.” Dr Neuss said that measurements need to be incorporated into EHR systems “and into care at the time we’re delivering care.” No EHR vendor has yet integrated ASCO or other measures into their base system, he said.

Data in the Public Domain

Much data are already available in the public domain to drive value-based decisions, argued Dr Sagar. She cited a recently published cost comparison of pamidronate, zoledronic acid (Reclast), and denosumab (Xgeva, Prolia) at their approved dosing schedules, in which the price differential between the lowest- and highest-cost regimens for 1 year of treatment exceeded $25,000. “We should be able to look at it and take advantage of that information,” Dr Sagar said. Cigna is exploring ways to use such data without dictating choice to the physician, she said, requesting that NCCN release categories of preference when recommending therapies in its guidelines. These data should also be available to patients. “Part of our commitment to better value in cancer care is exactly that: getting the right information into the hands of clinicians and patients at the point of decision-making,” said Mr Burk­holder. “You do need to make sure there’s a certain level of rigor to the data, whether it’s from a clinical trial or from real-world experience, to know that it is adequate for the decisions that you are making,” he added. “One of the basic things we can do is put better tools for that decision support into the hands of patients and clinicians so that they can act on best available evidence to make the decision that’s right for that individual patient,” Mr Burkholder said. Asked whether those tools should include comparative pricing information, Mr Burkholder said that patients should know their expected out-of-pocket costs when discussing therapeutic options with their physicians. Sometimes, physicians need to rely on data “that’s just good enough,” noted Dr Newcomer, recognizing the difference between real-world data and the data that the FDA demands for study registration. As long as the methods to derive cost comparisons are transparent, the data, even if not perfect, should be made available. “Don’t kill it with regulations and make it so perfect that it never sees the light of day,” he said.

Financial Incentives

Taking care of the patient is always the first priority, said Dr Kline, but financial incentives must be aligned. “One of the ways you bring value into the system is by taking a physician practicing and say, ‘Look, if you can provide high-value care, we’re going to give you a performance bonus.’ That’s the way the rest of the economy works,” Dr Kline said. When challenged that CMMI will not allow a higher cost for better patient care, Dr Kline responded that CMMI does take into account national medical expenditure trends in developing the OCM.