Managed Care Audience Hears ASCO's Peter Yu, MD, Describe Value-Based Efforts

The rising cost of cancer care in the United States, and the need to listen to what cancer patients want is not only transforming the way Americans deal with health insurers, but also the way physicians practice medicine, Peter P. Yu, MD, president of the American Society of Clinical Oncology (ASCO) said early today.

Dr Yu gave the morning keynote address at Patient Centered Oncology Care, the annual multistakeholder meeting of payers, providers, policy leaders and representatives from the pharmaceutical sector sponsored by The American Journal of Managed Care. This is the third annual gathering in Baltimore, Maryland, seeking better solutions for cancer patients in managed care. Burton VanderLaan, MD, of Priority Health was scheduled to give the afternoon keynote address.

The changing value proposition is causing oncologists to ask, “What does it mean to be a doctor in the United States?” Dr Yu said, in opening his talk. Physicians can no longer be someone who does things to patients, but must be someone who does things with patients. The cancer patient must be part of the decision-making, because the implications of care have changed so much.

Later on, he described a role for software makers in designing programs that would incorporate patient preferences into pathway designs. Dr Yu was optimistic about the role of Big Data in the future of cancer care.

He sees challenges ahead in holding down costs. Historically, discussing the price of therapy with patients was verboten for physicians, but issues of value and quality is something that ASCO has taken on in 2014. This spring, CMS agreed to use ASCO’s quality standards as a clinical data registry. ASCO collected data from payers and engaged in extended discussions, and is now is working with Congress to redesign Medicare reimbursement to be less complex and reward quality.

There’s simply no avoiding that the rising cost of specialty drugs is biggest cost driver in cancer care, Dr Yu said. He shared data from Blue Cross Blue Shield Association showing a 900% escalation in cancer drugs between 1996 and 2010, and data from PriceWaterhouse Coopers showing that the current $87.1 billion expenditure on specialty drugs is expected to quadruple by 2020.

More critically, the out-of-pocket costs for patients are rising; 34% of employers now charge at least a $60 co-pay for specialty drugs. How does that play out in cancer care? It means a patient who needs to take a pill a day for chronic myeloid leukemia might take a pill every other day, and is likely to relapse when there’s no reason for that to happen, Dr Yu said.

“We need to consider the more than the price of the drug,” he said, “We need to consider using or not using the drug.”

At the practice level, regulatory pressures, the way cancer drugs are priced and delivered and and the trend toward consolidation have made it difficult for small oncology practices to stay afloat, Dr Yu said. This presents a challenge in rural areas, where the community oncology clinic may be the only option. After Dr Yu spoke, Ted Okon of the Community Oncology Alliance said no one should believe that cancer patients will travel any distance for care; often, they simply wait until they become ill and go to the emergency room.

Dr Yu discussed principles of the payment reform initiative that ASCO is pursuing with Congress:

• Reimbursement must move away from fee-for-service toward value, but also away from the idea that payment must be tied to the physician touching the patient. Work by nurses, nutritionists and other team members is essential and should be reimbursed.
• Contact with the patient outside the office visit—especially during the survivorship stage—needs to be recognized.
• Flexible payment models must match the transition to value-based care. Excessive documentation is wasteful. Documentation should be streamlined and predictable.
• A model advocated by ASCO trims codes from 58 codes to 11.
• A bundled model can work, but the period of the bundle should be one month, since cancer patients’ status can change rapidly.
• The model must support clinical trials and transitions in care.