The Cost Conundrum in Cancer Care

At the NCCN Policy Summit on Value, Access, and Cost of Cancer Care, experts joined moderator Scott Gottlieb, MD, fellow at the American Enterprise Institute, and a panelist himself at The American Journal of Manages Care’s Spring Oncology Stakeholders Summit. Participants included Steve Miller, MD, MBA, chief medical officer, Express Scripts; Barbara Parker, MD, deputy director of clinical affairs, University of California San Diego Moores Cancer Center; Gayle Petrick, director of the American Cancer Society/Patient Advocate Foundation partnership program; Michael Rabow, MD, chair of palliative care and professor of clinical medicine and urology, UCSF Helen Diller Family Comprehensive Cancer Center; and Warren Smedley, MSHA, service line director for cancer and GI services, University of Alabama at Birmingham Comprehensive Cancer Center.

Dr Gottlieb began the dialogue by pointing out that overall, cancer spending has been relatively flat for a while. However, the spending mix has seen dramatic changes…drugs and care costs have seen a big jump, he said, asking the panel’s opinion on whether they believed this to be an insurance versus a spending problem.

“I think it’s both,” said Dr Parker. “Our ageing population is doing much better with surviving heart disease. So more patients are getting cancer,” she added. According to Dr Parker, the spending trouble that patients experience are primarily in the outpatient rather than the inpatient setting and it relates to their level of insurance.

In Dr Miller’s opinion, the rise of drug spending has been extraordinary. “We are in the perfect storm. We are maximally using generics…so the shift to generic use has actually dropped. But biosimilars might change this landscape,” he said, adding that the fastest rising cost in all of healthcare is now drugs.

“Is our goal to capitate?” asked Dr Gottlieb.

“We need to develop tools for our providers to decide or choose treatment regimens. Teams should work with payers and with other institutions to generate guidelines within our insurance environment,” said Dr Parker.

Dr Gottlieb then turned to the palliative care expert on the panel to discuss the impact of a parallel introduction of palliation in the care regimen. How early can this be done and is there data to show it can significantly impact costs?

“What makes hospitalization avoidable is a question that can be asked,” replied Dr Rabow. Emphasizing the importance of discussing available choices with the patient, he said, “We don’t ask or educate people about these choices.” This point was also highlighted by several experts who contributed to the palliative care issue of Evidence-Based Oncology. “The data shows that the earlier you institute palliative care in a concurrent or parallel model, the greater impact it can have on healthcare utilization,” continued Dr Rabow. He then discussed data from a study that found palliative care consultation 2 days, versus 6 days, into hospitalization resulted in significantly increased savings.

The question however remains, how early is “early”? Can it be initiated right from the time of diagnosis? According to Dr Rabow, the time to initiate palliative care should be decided on a case-by case basis. The other aspect is “Who renders the care for a cancer patient? Should there be a palliative care specialist or can the oncologist play the role? How do you distribute the resource of palliative care?”

Mr Smedley pointed out that many patients are not equipped with enough information or are not involved at a level to make care decisions, which underscores the important role played by patient navigators. “Our program has resulted in annual savings of a $121 million on unnecessary services that were eliminated. [Emergency room] and unnecessary hospital stays and ICU stays have significantly reduced at our facility. This is in a population of 2000 patients and we have separated them into cohorts based on their need levels—the sicker patients versus the not as sick.”

According to Dr Miller, the recent price wars with novel hepatitis C treatments were a result of formulary tiers or preferred drugs on the formulary—a move that “resulted in a 50% decrease in drug price.” He thinks a similar model could emerge with cancer drugs. "Biosimilars could likely bring about this change," he said.