Stakeholder Definition of Value in Cancer: Where Are We 1 Year Later?

Most alternate payment models being proposed today—whether generated by professional organizations like the American Society of Clinical Oncology (ASCO), by CMS, or by private payers—have an associated “value” attribute. While clinical data presented at the annual meeting of ASCO created waves, a session on value had an equally significant impact as throngs of oncologists came to hear stakeholder voices define this as yet abstract concept of “value” in cancer care. The session brought together a patient representative, an oncologist, an ASCO representative, and a payer.

ASCO’s Value Initiative

Lowell E. Schnipper, MD, chief of hematology/oncology at the Beth Israel Deaconess Medical Center, provided his insight into ASCO’s Value Initiative.

Defining clinically meaningful outcomes is the foundation of the Value Initiative, said Schnipper. He informed the audience that ASCO has invited multiple stakeholders to submit their comments on the initiative, with the objective of finding a meaningful balance among clinical benefit, side effects, and financial toxicity. He acknowledged that this is “a fairly difficult act.” While metrics are essential to support these outcomes, said Schnipper, “The question is, ‘What are the clinically meaningful outcomes and who defines them?’”

Schnipper went on to define some of the clinical trial end points most commonly used to ascertain clinical benefit: overall survival (OS), progression-free survival, palliation, and toxicity. Surrogates such as complete response and partial response, he said, are primarily used for breakthrough therapy designation by the FDA. While palliation is important in the advanced disease setting, he added, OS and disease free survival are important in the adjuvant setting, and toxicity is also a clinically important variable in advanced disease and in the adjuvant setting.

Of course, another important factor is cost. Schnipper said healthcare policy decisions can be made based on quality-adjusted life-years, which includes both the quality and the quantity of life post intervention in the value discussion.

ASCO, Schnipper said, is developing a value framework that can be implemented at the doctor-patient interface. ASCO plans to open up the framework for public feedback, with the objective of improving the tool.

Oncologist Defines Value of Care

Presenting the clinician’s definition of value in cancer care was Neal J. Meropol, MD, professor and chief of the division of hematology/oncology at Case Western Reserve University School of Medicine. “I’ll provide more of a physician perspective,” he said, “based on what I hear from my patients about the cost or value of their treatment.”

A few of the commonly expressed concerns he listed were:

• The cost of traveling to the site of treatment
• Insurance coverage and co-payments
• Need for a specialty agent
• Denial of payment for recommended care.

“Oncologists cannot be the gatekeepers based on cost; rather, we have the opportunity to be gatekeepers based on value,” said Meropol.

He showed data from studies documenting that the out-of-pocket (OOP) costs in cancer care are greater than with other chronic diseases. Also, the rate of bankruptcies has been documented as being significantly higher among cancer patients than in individuals without a cancer diagnosis. OOP expenses, he said, have been associated with disparities in care. He cited as an example the fact that Medicare patients with private supplemental insurance have been shown to receive their required chemotherapy, while those without the private supplemental insurance have a lower probability of receiving it.

“Patients are open to communicating with their doctors about their cost burdens,” said Meropol, and cost concerns may result in patients borrowing money from family or friends, draining their own retirement accounts, or making sacrifices to ensure continuity of treatment. There’s racial disparity as well, he pointed out, and “economic hardship” was reported to be higher in minority populations in the first year of their cancer treatment.

However, Meropol noted, “A majority of patients, we need to keep in mind, have been shown to equate quality of life with length of life.” They are also ready to pay for higher-value care if they are assured of better outcomes.

But what do oncologists think?

Meropol cited results of a study published in the Journal of Clinical Oncology nearly a decade ago, which suggested that 13% of surveyed oncologists did not have a good sense of their patient’s monetary concerns as they underwent treatment. While 33% of the medical oncologists said they were not comfortable discussing cost, 25% did not discuss the financial aspects at all.¹

Economists hypothesize that physicians are incentivized by financial reimbursements, said Meropol. “To avoid these perverse incentives, we do need alternate payment models such as bundled payments, value-based insurance, and pay-for-performance.”

Finally, Meropol highlighted some of the tools needed at the point of care to help providers make informed decisions when choosing “valuable” treatments:

1. What’s the relative value of different treatment options?

2. What are the anticipated OOP costs for my patients?

3. What are my patient’s goals and preferences?

4. What is the best way to communicate these issues to my patients?

The Payer’s Viewpoint

A third presenter at the session was Jennifer Malin, MD, staff vice president of clinical strategy at Anthem Inc, who discussed “Value From the Payer Perspective.” According to Malin, the ultimate payer is the employer and/or the patient. “Our discussions today should not look at the influence on immediate [health] concerns; rather they should help patients make informed decisions about their future—about their insurance coverage and deductibles and co-pays—which would impact healthcare overall,” she said.

Malin introduced Anthem’s clinical pathways program, which identifies high-value regimens to help curb treatment costs. Her organization, she said, views evidence from trials and publications; the information is then extracted, reviewed, and analyzed. Malin explained that external experts from various cancer centers and community practices are assigned the task of assessing clinical benefits, toxicities, and cost, in order to select those regimens that can be appropriate in 80% to 90% of patients. This pathway can then provide a global frame of reference.

Introducing Anthem’s quality initiative, the “Cancer Care Quality Program,” Malin said the Web-based platform includes the prior authorization requirement as well, which can improve efficiency.

“It is important to think about value for all stakeholders. Reimbursement needs to be aligned to achieve desired outcomes while providing quality care,” emphasized Malin.

Patient Representation

In contrast with the 2014 annual meeting, this year ASCO invited a patient advocate to participate in the value discussion. “Patient Priorities on Value in Treatment Choices” was the title of the talk by Beverly E. Canin, Breast Cancer Options, Inc.

Canin pointed out the need to find common ground between physicians and patients, which, she emphasized, should be based on “do no harm.” She acknowledged, however, that with a disease as hard to treat as cancer, “do no harm” is a difficult goal.

Canin said that when doctors are asked about value in cancer treatment, they do not necessarily associate cost with value. In the case of patients, several of them talk about their ability to communicate with their treating physicians as a “value” concern.

She shared results from one such study which found that more than 38% of patients defined value in terms of “personal value,” meaning their own personal goals and objectives, while 7% defined it in terms of “exchange” value, referring to the communication they have with their providers.

Canin emphasized the fact that the term “value” needs to be clearly defined to patients: “A clear communication is needed.” Referring to a quote from Linda House, president, Cancer Support Community, Canin said there might be a disconnect between what the physician recognizes as a valuable treatment and how the patient understands it.

She aptly ended her talk with George Bernard Shaw’s quote, “The problem with communication is the illusion that it has occurred.”

Reference

1. Schrag D, Hanger M. Medical oncologists' views on communicating with patients about chemotherapy costs: a pilot survey. J Clin Oncol. 2007;25(2):233-237.

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