The Tightrope Act of Personalized Value in Cancer Care

Most of us who are familiar with the oncology value models proposed by organizations like the American Society of Clinical Oncology, the National Comprehensive Cancer Network, and others, realize the myriad practical questions that these models create for those on the frontlines of cancer care delivery. Unless these frameworks are implemented in the clinic, questions will remain with respect to their utility. But implementation of these tools may require educating not just the providers, but also patients and payers.

To discuss these and other challenges with transitioning to value-based care, the Association of Community Cancer Centers (ACCC) invited a panel of experts during its 42nd annual meeting on policy, value, and quality, currently ongoing in Washington, DC. The panel, moderated by Christian Downs, JD, MHA, executive director of ACCC, included Alan Balch, PhD, chief executive officer, Patient Advocate Foundation (PAF); Thomas A. Gallo, MS, executive director, Virginia Cancer Institute, Inc; and George Kovach, MD, Iowa Cancer Specialists.

Balch explained how his organization functions. He explained that they have 2 separate entities to their foundation. PAF provides patient support and guidance on patient access issues as well as financial problems that patients face pertaining their care. The National Patient Advocate Fund, he explained, is their policy and advocacy wing.

Coming back to the topic at hand, Balch said, “There’s need to standardize the frameworks to improve system efficacy.” There are 2 ways to approach this, he explained, “decide the patient’s faith beforehand or discuss the options with them and personalize their journey through the disease.” Balch believes that the ideal provider-patient conversation should be around goals of concordant care. “Over-standardization runs the risk of losing out on goal-concordance and what is valuable for the patient,” he said. However, Balch feels that discussions around cost of care and affordability, which are so important for the patient, are the most difficult to handle. “I am not sure when the right time is to introduce that conversation, because it can stress the patient, but it needs to be done in a way that is meaningful to the patient,” Balch added.

Gallo provided an operational perspective on this move to value-based care. “Physicians usually stay out of the conversation on finances because they are not comfortable with it. A lot of different frameworks and programs make it difficult operationally. We are still experimenting with the various options and trying to place programs in place to bring value. The burden is huge on the clinics because it takes time away from focusing on the patient,” he said.

Balch added that the patient is faced with a lot of information all at once when it comes to a cancer diagnosis. They are overwhelmed since they are expected to understand and make decisions on a lot of clinical issues. Discussions on the financial aspects of care just add to the burden, Balch said, adding that “it should be a precision conversation.”

“Insurance has changed and out-of-pocket costs have risen significantly,” continued Gallo. “Further, the lack of oral parity creates additional burden. It’s bad enough that the patients are worried about their diagnosis, and then over and above that they are required to have the conversation on financial issues.” He said that they have a very good team of financial counselors at the Virginia Cancer Institute that provides their patients the best information and guidance to navigate the journey.

Kovach, however, raised the issue of ‘insured but not covered.’ “A problem we have missed discussing is that many of these patients have insurance but they are not necessarily covered for their required treatments.”

Balch noted that not all patients would necessarily be interested or keen on understanding or discussing the cost of care. “The pace and scale at which they would want that information is what could be operationally difficult,” he said.

Kovach added that as a physician, he tries his best to do everything on his end to insulate them as much as he can with issues of cost and access. “I believe that physicians really need to be involved in this,” Kovach added.

Gallo raised concerns with the rising administrative burden that oncologists face. “Most are already overburdened in the clinic. The fact that some of these frameworks have an information deficit just makes it that much harder,” he said. “If we can have a global approach for harmonizing the process, it’d definitely help,” Gallo continued. “Something like a common patient assistance form would ease matters so much more for us operationally. Standardizing would be a big help.”