Making Progress, or Headed for Crisis? NCCN Keynotes Offer Contrasting Views of US Cancer Care

The second day of the National Comprehensive Cancer Network (NCCN) 23rd Annual Conference in Orlando, Florida, opened with a dual keynote presentation on transforming cancer care in the United States.

Opening the presentation was Ron Kline, MD, FAAP, medical officer in the patient care models group at CMS’ Center for Medicare and Medicaid Innovation. Kline, who remains a practicing pediatric oncologist, opened by assuring those participating in the Oncology Care Model (OCM) that their feedback on and concerns about OCM are being heard, even if the agency has not directly replied to comments from individual practices: “We know you have to keep your doors open, [and] we know about the burdens. We do listen to you. Many of you acknowledged problems in OCM. We’ve changed those things, and we’ve listened... If you hear nothing from us, that doesn’t mean we haven’t heard you.”

Kline also acknowledged that OCM is a difficult program to implement, saying, “If OCM was easy, someone would have done it 20 years ago.” Yet CMS has not instituted an unfunded mandate; with its monthly enhanced oncology services payments, “We put $80 million of skin in this game…We’re giving you the tools to do these things.”

Despite the challenges of implementing OCM, Kline says that preliminary results from the first reporting period show progress. Twenty-five percent of Medicare fee-for-service (FFS) chemotherapy-related cancer care—in 187 practices for 150,000 unique beneficiaries each year, representing approximately 200,000 episodes of care—is now given under OCM, and 14 commercial payers are also now participating in the model.

The Institute of Medicine (IOM)’s Care Management Plan is having a positive impact on patient care, says Kline. Some oncologists have argued that the 13 components of the plan are tasks they are already undertaking, only without documentation; Kline agrees that “the 13 components of the [IOM] care management plan are things that a good oncologist should be doing anyway.” However, some oncologists have had to be pushed to talk to patients about prognosis, as they felt that it was too depressing for patients to know their prognosis. Implementing the IOM plan has compelled them to have these difficult discussions with their patients.

Furthermore, Kline says that some practices are beginning to provide the enhanced services of OCM—such as around-the-clock patient access to an appropriate clinician—to all of their oncology patients, regardless of their health plan, as a means of streamlining processes and improving care. “When we hear that, that’s music to our ears,” said Kline. “One of the nice things we hear from practices is ‘you know what, we’re providing the care we always wanted to provide.’ That’s where you want to be.”

Following Kline was Lee N. Newcomer, MD, MHA, a private consultant who recently retired from his position as senior vice president of oncology and genetics at UnitedHealthcare. Newcomer gave a sobering figure: The medical expenditure of the United States is equal to the fifth largest national gross domestic product (GDP) in the world; what the United States spends on healthcare is in fact larger than the GDP of France. “If we don’t fix this problem…we’re going to have a crisis, and a big one,” he said.

Newcomer cautioned that reimbursement strategies alone will be insufficient to solve this problem; roughly 80% of this growth in spending, he said, is not driven by providing more care, but by rising prices. “It is a failed system,” he said, that is driving an interest in value-based bundles.

UnitedHealthcare attempted a pilot a bundle for the treatment of head and neck cancers together with the MD Anderson Institute, and used treatment strategy (eg, surgery, radiation, surgery plus radiation) as the basis for the bundle. Each bundle had a different dollar amount attached to it, with the same profit margin for all categories.

“The purpose of the program was [to see] if we could even do it.” The answer, said Newcomer, was “yes, but not without a lot of extra resources” to coordinate. “There were too many resources for too little gain—not that it was a bad idea. What we learned is we have to have something we can spread over thousands of patients.”

In a UnitedHealthcare trial of a gain-sharing arrangement in patients with cancer, 810 patients were matched with a cohort of FFS patients. In total, it cost $99 million to treat the FFS group and $65 million to treat the gain-sharing arrangement group. Hospitalizations declined, and survival curves in lung cancer were the same in both groups. “A huge, whopping win,” Newcomer said. Unfortunately, in a second instance of the program, there were no differences in costs between groups. These experiences proved, said Newcomer, that leadership is essential, and internal controls and timely data are critical. “Without those elements, things tend to fall apart.”

Newcomer argued that, in order to make a real difference in costs, “We have to get rid of the mandates that require every payer in the US…to pay for any drug that has an FDA cancer approval.” The mandate is well intended, said Newcomer, “[But] the unintended consequence is that it’s limiting access to cancer care…making it too expensive.” With no ability to negotiate, there’s nowhere for prices to go but up, putting a high burden on vulnerable patients with cancer.

Newcomer welcomes the advent of more data in oncology, and says that, in the coming years, practices will be able to see more clear information on which therapies cost more without providing substantial benefit. Newcomer pointed to the cost of zoledronic acid versus the cost of denosumab as a prime example of the kind of data that clinicians need for better decision making. “Are we really getting $25,000 worth of benefit” from denosumab versus the far cheaper zoledronic acid? “I would argue no,” said Newcomer.

Yet these data will only be useful if clinicians use them to make prescribing choices that optimize value in oncology care. Newcomer ended with a challenge to oncologists to take charge of the cost of care: “You have the power to do something about this…the people who will make this happen, are sitting right out there. I’m looking at you.”