Assessing and Improving Value in Cancer Care Workshop Summary (2009) / Chapter Skim
Currently Skimming:
8 Improving Value in Oncology Practice: Ways Forward
8 Improving Value in Oncology Practice: Ways Forward
Pages 85-108
The Chapter Skim interface presents what we've algorithmically identified as the most significant single chunk of text within every page in the chapter.
Select key terms on the right to highlight them within pages of the chapter.
From page 85... ...
By the same token, patients should bear a greater financial burden for care that has marginal value so as to encourage efficiency. VBID recognizes that patient demand and preferences should play a role in the care delivered and that patients should share some of the financial burden, but it also recognizes that standard economic demand theory should not be blindly applied.
|
From page 86... ...
This problem is termed moral hazard, and it drives people to consume excess care and leads to high premiums when patients are insulated from the full costs of care. Models of cost sharing should not be designed to lower premiums but rather to improve patient incentives and reduce excess use while encouraging price shopping.
|
From page 87... ...
. Another program for public employees in California increased co-pays and found that they were able to save 20 cents for every dollar spent on extra drugs; the program 14% Decrease in Non-Adherence 12% 10% 8% 6% 4% 2% 0% Ace/ARBS Beta Diabetes Statins Steroids Blockers Drug Class FIGURE 8-1 The impact of value-based insurance design upon adherence to ACE inhibitor, beta-blocker, glucose control, statin, and inhaled corticosteroid therapies.
|
From page 88... ...
As a society we should make sure to slow health care growth in a way that minimizes adverse consequences and allows people access to high-value care. If we do not have the courage to determine what has high value and what does not, we will simply discourage use of services indiscriminately, and that would risk driving patients to lower-value care instead of promoting health care that is of high value.
|
From page 89... ...
Tunis explained that the uncertainty pathway begins with intellectual curiosity that feeds clinical research, which in turn produces published studies and information that slowly travel by passive diffusion (knowledge translation route 1 [KT1]
|
From page 90... ...
has a lengthy history of involve ment in generating better evidence for policy decision making, from the investigational device exemption for coverage of certain devices in clinical trials (1996) , to coverage for routine costs for patient care in clinical trials (2000)
|
From page 91... ...
is Medicare's attempt to reduce uncertainty by linking reimbursement for emerging, promising technologies to a requirement for prospective data collection on those technologies through clinical research studies. Medicare retains the authority to approve the design to those clinical studies based on whether they are sufficiently robust to allow Medicare to decide whether the technology is clinically reasonable and necessary and improves health outcomes for patients.
|
From page 92... ...
Tunis's Center for Medical Technology Policy (CMTP) and others are pursuing this work in areas where treatment methodologies have rarely been studied side by side, and significant gaps in clinical knowledge still exist, such as in the treatment of clinically localized prostate cancer (Wilt et al., 2008)
|
From page 93... ...
Percentages should be reinforced with frequencies, and any numerical information should be reinforced visually. Pictographs improve comprehension better than other visual aids, such as bar graphs or pie charts, because pictographs help people quickly grasp the information relevant to their decision.
|
From page 94... ...
FIGURE 8-3 Statistical representation of the added mortality benefit of chemotherapy for breast cancer in addition to hormone therapy using a bar graph versus a pictograph; statistical benefit shown asFigure 1-3 redrawn.eps 2 more women out of 100 alive because of additional chemotherapy. SOURCE: Ubel presentation, February 9, 2009.
|
From page 95... ...
For angioplasty, two stories told of a cure and two did not, matching the 50 percent success rate given for the treatment. With the stories better aligned with the statistics, subjects chose bypass twice as often as before, or 41 percent of the time.
|
From page 96... ...
CONCRETE IDEAS FOR INCREASING VALUE IN ONCOLOGY CARE: A VIEW FROM THE TRENCHES Dr. Smith began by saying that his presentation would address a number of topics, including unrealistic demands for treatment benefit, low reimbursement for cognitive care, high reimbursement for chemotherapy or infusions, the high-income expectations of oncologists, variable quality, and stress and burnout.
|
From page 97... ...
High Reimbursement for Chemotherapy and Infusions The majority of community oncology practice reimbursement comes in the form of noncognitive care. In 2006, the median oncologist's yearly salary was $358,000, the mean was $523,000, and the 90th percentile made over $1 million.
|
From page 98... ...
Within the current oncology payment structure, there is little reward for having a patient discussion on withholding chemotherapy because doing so is harder emotionally and will reduce reimbursement for the practice. Regarding our current incentives, Dr.
|
From page 99... ...
Lastly, there is little interest in performing noninferiority trials to show treatment equivalency, though it could save society considerable amounts of money. Potential Oncology Practice Solutions Dr.
|
From page 100... ...
FIGURE 8-4 Example of truthful patient information regarding metastatic cancer: fourth-line therapy for breast cancer. SOURCE: Smith presentation, February 10, 2009; from GO8 NLM009525 Smith T (PI)
|
From page 101... ...
by ______months • Shrink my cancer in half in ___ of 100 people like me • Shrink my cancer completely in ___ of 100 people like me • Keep my cancer stable for ___ months in ___ of 100 people like me • Improve my cancer symptoms in ___ of 100 people like me Patient signature: _____________________________________ MD signature: ________________________________________ Physician documentation of patient ECOG Performance Status, 0 to 4 (circle one) : 0 – no symptoms 1 – symptoms but normal activity 2 – symptoms but still functioning 3 – in bed or chair ≤ 50% of the day 4 – in bed or chair ≥ 50% of the day
|
From page 102... ...
Though it will be very complicated to develop capitated or illness-based episode payments, reimbursement could be reduced for chemotherapy to 6 percent over the average sales price. Furthermore, there should be a reward for oncologists who follow National Comprehensive Cancer Network (NCCN)
|
From page 103... ...
Variable Quality of Care The American Society of Clinical Oncology's Quality Oncology Practice Initiative has successfully assessed oncology practices for adherence to published guidelines. Could this model be applied to assess the number of practices with appropriate counseling and social work staff?
|
From page 104... ...
This can be accomplished by working with private payors and Congress to realize Medicare reimbursement that values cancer care and survivorship care planning as fundamental elements of quality care. Finally, patient and physician education are needed, as well as close collaboration with those in the caregiving community to improve value in cancer care.
|
From page 105... ...
Dr. Tunis responded by saying that it would be a very good idea to explicitly provide economic information on comparative costs of alternative treatments in the guidelines but perhaps not to integrate this fully into the clinical recommendations.
|
From page 106... ...
2003. The Asheville Project: Long term clinical and economic outcomes of a community pharmacy diabetes care program Journal of the American Pharmaceutical Association 43(5 Suppl)
|
From page 107... ...
2009. National Comprehensive Cancer Network guidelines: Non-small-cell lung cancer and breast cancer.
|
Key Terms
This material may be derived from roughly machine-read images, and so is provided only to facilitate research.
More
information on Chapter Skim is available.