Roundtable Finds Little Consensus on How to Define "Value" in Value-Based Care

During a Friday session of the National Comprehensive Cancer Network 23rd Annual Conference in Orlando, Florida, Cliff Goodman, PhD, of the Lewin Group, moderated a multi-stakeholder panel discussion on delivering and receiving cancer care in value-based care models.

On the issue of whether the healthcare system is generating more value in oncology, Michael N. Neuss, MD, of Vanderbilt-Ingram Cancer Center, said, “We are making progress.” For Neuss, the key will be better reporting that will help to identify best practices by using good data. The application of data, said Neuss, will drive oncologists to change their prescribing practices. “There’s been a lot of maligning of pharma, [but] when you show us what [drug expenses are], they come down,” he said, adding that oncologists are “embarrassed” by high drug costs.

Daniel P. Mirda, MD, of the Association of Northern California Oncologists, was cautious about whether such data can be derived by more use of electronic health records (EHRs), saying that many oncologists feel that EHRs actually interfere with value. Yet Mirda believes that there is growing awareness of financial toxicity, which is key to creating change.

Mirda reported that many patients come back to the clinic to discuss other treatment choices because they cannot afford their drugs; “their co-pay is insurmountable.” Oncologists must help patients on a basic level by understanding and responding to their financial challenges.

“All of us want to give patients the best option … [but] we have to look for second choices,” because of financial toxicity. However, “We’re very careful about suboptimal care…how we’re going to judge value is going to be an important point.”

Travis H. Bray, PhD, of the Hereditary Colon Cancer Foundation, was less optimistic that greater awareness of financial toxicity is making an impact on the value that patients derive from care; Bray said that most patients with cancer have moderate to catastrophic financial difficulty: “There’s a bunch of money coming from one direction going somewhere else.” While the care delivery system is aligned to generate value, he said, “it’s aligned to generate value in the opposite direction from patients.” As survival of colon cancer has not increased by substantial margins in recent years, he said, he finds it difficult not to be jaded by the increasing cost of care.

Randy Burkholder, of PhRMA, responded with a different construct of value: “Value means delivering better treatment … lot of conversation this morning has been under the frame of value, but it’s really focused on cost.”

Lee N. Newcomer, MD, MHA, a private consultant formerly of UnitedHealthcare, responded, “I don’t begrudge a pharmaceutical firm a profit. They should have it… What I’m asking for, as a capitalist, is a free market” with competition. “Good old-fashioned market force” will benefit patients, he said, echoing his earlier remarks in his keynote presentation in which he called for a rollback of mandates that require plans in the United States to cover all approved cancer drugs. Newcomer argued that this mandate leaves little room for plans to negotiate on price.

Burkholder told Newcomer, “you have [negotiation] tools at your disposal,” on the payer side, and called the mandate’s provisions “basic protections.”

Ron Kline, MD, FAAP, of CMS’ Center for Medicare and Medicaid Innovation, responded, “We need to have a free market so you have access to multiple drugs, but from the standpoint of [the Oncology Care Model, OCM], physicians have to care” about prescribing drugs that are high cost without delivering a substantial benefits. “[OCM] says look for value and take good care of your patients. Look for when you can accomplish the same goal at a higher value.” He added that “We hear from oncologists that ‘pharmaceutical reps used to come in and buy us lunch. Now they come in and tell us why their drug has greater value.’”

Mirda, whose organization is not part of OCM, said that he would like to see more data to help drive good decision making. “We are not businesspeople. We don’t know the cost factors, we’re not directly involved in that,” said Mirda. “We need an OCM-like administration.”

Kline responded that an under-celebrated part of OCM is a 40-page quarterly report on how each practice is doing compared to other OCM practices and the non-OCM world. Bhuvana Sagar, MD, of Cigna, said that her organization is working to gather more data to tie to claims and provide more granular information to inform their decision making.

Newcomer added that data need to be delivered in real time so that practices can likewise make decisions in real time. Even internal data can be made useful, said Newcomer, cautioning practices against waiting for the “right” data sources. Practices should not subvert the purposes of data “by making it so perfect that it never sees the light of day.”

Kline noted that it is possible to apply sensitivity to cancer care by providing appropriate therapy to individual patients by being thoughtful of about the use of resources. And under OCM, “If you provide high-value care, we’re going to give you a bonus. All we’re doing is asking people to think a little bit.”

Sagar agreed, saying that oncology must look beyond drug prices along to assess the overall appropriateness of care.

Closing the panel, Burkholder said that, in terms of the improvements that oncology drugs have provided, the prices charged by drug manufacturers are “absolutely” appropriate. “In terms of total death rates,” he said, new medicines are providing commensurate value. “You have to look at the whole system.”