Delivering Affordable Cancer Care in the 21st Century Workshop Summary (2013) / Chapter Skim
Currently Skimming:
Workshop Summary
Workshop Summary
Pages 1-74
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 1... ...
. In spite of health care costs that far exceed those of other countries, health outcomes in the United States are not considerably better (Fineberg, 2012; IOM, 2010b, NRC and IOM, 2013)
|
From page 2... ...
With the goal of ensuring that patients have access to high-quality, affordable cancer care, the Institute of Medicine's (IOM's) National Cancer Policy Forum convened a public workshop, Delivering Affordable Cancer Care in the 21st Century, October 8–9, 2012, in Washington, DC.1 Workshop presentations and discussions examined the drivers of current and projected cancer care costs, including • inappropriate financial incentives in the health care system; • unrealistic expectations about the effectiveness of screening and treatments for cancer by both patients and clinicians; • overuse and misuse of medical resources and inadequate adherence with treatment guidelines; and • lack of evidence on what represents high-quality, affordable cancer care.
|
From page 3... ...
Beginning on page 29, the workshop summary describes possible solutions in more detail, organized by: • patient and clinician communication and education • best practices in cancer care • evidence base for clinical practice and reimbursement • financial incentives aligned with affordable, high-quality cancer care • delivery system and reimbursement changes A recurring theme of the workshop was the need for all stakeholders -- including patients, clinicians, private and government payers, and the pharmaceutical and device industries -- to work together to address affordable cancer care. In addition, several workshop speakers suggested that strategies for controlling cancer care costs are likely to be applicable to reducing health care costs in general.
|
From page 4... ...
We have to face this problem," stressed Scott Ramsey, full member of the Fred Hutchinson Cancer Research Center and professor of medicine at the University of Washington. The United States spends far more than other nations on health care, in proportion to its earnings as a nation (see Figure 1)
|
From page 5... ...
life expectancy is slightly lower and its infant mortality rate slightly higher than that of Canada or Switzerland (OECD, 2011, 2013) , despite lower health care expenditures in both countries compared to the United States (OECD, 2011)
|
From page 6... ...
Emanuel argued that these rising health care costs jeopardize health coverage and access; state budgets and funding for education; middle-class wages; and the United States' long-term fiscal stability and status as a world power. Emanuel noted that one state budget director predicted Medicaid
|
From page 7... ...
. Household Income 50% of Household Income Family Health Insurance Premiums Family Premium + OOP Costs $120,000 $110,000 $100,000 $90,000 Household Income $80,000 $70,000 $60,000 $50,000 $40,000 $30,000 $20,000 $10,000 $0 2000 2005 2010 2015 2020 2025 2030 2035 Year FIGURE 2 Projected annual family health insurance premium costs and average house hold income in the United States.
|
From page 8... ...
"If we are going to succeed in reaching affordable cancer care and an affordable health care system, we have to focus on the total costs." Emanuel attempted to dispel some common misperceptions about the drivers of escalating health care costs. He said physicians tend to blame much of the rising costs on the practice of defensive medicine,2 medical malpractice, insurance company profits, drug costs, and demanding patients.
|
From page 9... ...
Speakers discussed other drivers of rising health care costs, including financial incentives driven by fee-for-service reimbursement that reward volume of care rather than quality or efficiency of care, and a lack of focus on system and individual patient costs of treatment. Additionally, innovation and the diffusion of new technologies in care and a lack of coordination among providers, hampered by a lack of interoperability of EMRs, have also led to high health care costs.
|
From page 10... ...
Leaders from the cancer community reviewed the evidence on international cancer costs to compose a public policy perspective on delivering affordable cancer care in high-income countries for Lancet Oncology, reported Jeffrey Peppercorn, associate professor of medicine at Duke University and faculty associate of the Trent Center for Bioethics. These authors concluded that both the burden of cancer and the costs of cancer care are continuing to increase for high-income countries (Sullivan et al., 2011)
|
From page 11... ...
15,000 10,000 5,000 0 1960 1970 1980 1990 2000 2010 Year of FDA Approval FIGURE 3 Monthly and median costs of cancer drugs at the time of Food and Drug Administration approval, 1965–2008. Dots represent the cost of 1 month of cancer treatment for an individual who weighs 70 kilograms or has a body-surface area of 1.7 m2.
|
From page 12... ...
and MedPAC, 2012. since they are typically effective in smaller subgroups of cancer patients.
|
From page 13... ...
Financial Burden on Patients with Cancer Veena Shankaran, assistant member of the Fred Hutchinson Cancer Research Center, stressed the growing financial burden of cancer on patients and their families. She said cancer patients face significantly greater health care costs compared to those with other chronic conditions (see Figure 5)
|
From page 14... ...
. Some cancer care costs may not be necessary or can be avoided by opting for lower cost, but equally effective, options.
|
From page 15... ...
The median survival for metastatic triple-negative breast cancer6 is still a little more than 1 year and is the same or worse in many other major cancers." Ramsey added, "A lot of what we do in cancer is very expensive and actually offers very little for patients. In some cases, it may actually hurt patients." Lowell Schnipper, the Theodore and Evelyn Berenson Professor of Medicine at Harvard Medical School and clinical director of the cancer center at Beth Israel Deaconess Medical Center, added that "for the common types of cancer, the expenses are rising inexorably along with new innovations, but the extent to which they really make meaningful impact is not always clear." Fineberg stressed, "The crisis we have reached in health care [necessitates]
|
From page 16... ...
The current fee-for-service reimbursement structure provides an incentive to prescribe more chemotherapy and other expensive treatments even when the patient may not be likely to benefit from them, several speakers noted. "Giving the more expensive drug always gets us or our cancer center more money," Schrag said.
|
From page 17... ...
for 3-D conformal radiotherapy in prostate cancer, 2001–2005, and (b) the rapid adoption of brachytherapy as the sole modality of radiotherapy in breast cancer treatment, 2001–2006.
|
From page 18... ...
physicians, and health outcomes in Canada are good, according to Earle. Earle suggested that one reason health care costs are lower in Canada than in the United States for comparable quality is because Canada has substantially lower administrative costs (Woolhandler et al., 2003)
|
From page 19... ...
There can be long wait times for medical interventions as well as overtreatment issues. There is a need to improve its preventive services, and there are some inappropriate financial incentives, as most physicians still receive fee-forservice reimbursements.
|
From page 20... ...
. One study found that 81 percent of patients with metastatic colorectal cancer and 69 percent of patients with metastatic lung cancer did not report understanding that chemotherapy was not at all likely to cure their cancer (Weeks et al., 2012)
|
From page 21... ...
. Another study found palliative care consults reduced the cost of cancer care (Morrison et al., 2008)
|
From page 22... ...
. Denise Aberle, professor of radiology and vice chair of research in the University of California, Los Angeles, Department of Radiological Sciences, discussed the results of the National Lung Screening Trial, which found that screening with low-dose CT reduced mortality from lung cancer for those at high risk,9 and discussed the challenges of implementing screening in practice (National Lung Screening Trial Research Team et al., 2011)
|
From page 23... ...
Brawley also gave examples of several treatments that were used extensively before they were shown to be ineffective, and in some cases, even harmful. These treatments include postmenopausal hormonal therapy, high doses of vitamins, lidocaine after a heart attack, and erythropoietin to stimulate red blood cell production in cancer patients.
|
From page 24... ...
Some of that variability stems from an inadequate evidence base (see also the section on the evidence base for clinical practice and reimbursement)
|
From page 25... ...
"A randomized trial may be the most efficient way and subject to the fewest confounders," said Kramer. "I think trying to rely on epidemiological evidence opens up the study design to a far larger range of confounding factors." Hu said that a randomized controlled trial with a single surgeon and third-party collection of outcomes data might be better suited to assessing new surgical innovations, but Kramer argued that this would lead to problems of generalizability.
|
From page 26... ...
The challenge of evaluating new surgical procedures for effectiveness has huge implications for system costs given that new surgical technologies are often more expensive, and because patients and providers rapidly adopt these new procedures. Prostate cancer patients are quickly migrating to hospitals that offer robotic prostatectomies, and because many as four out of five radical prostatectomies now use the da Vinci Surgical System robot (NCI, 2011)
|
From page 27... ...
Based on the later study findings, the approval of the drug for breast cancer was ultimately withdrawn, but by then, this expensive drug had already been widely prescribed for breast cancer patients. Assessing Value A great deal of discussion focused on how to assess the value of a specific medical intervention.
|
From page 28... ...
" He suggested it is easier to limit the use of no-value treatments and treatments that have not demonstrated value compared to lower-cost alternatives, such as Avastin for metastatic breast cancer or proton beam therapy for prostate cancer, versus low-value treatments that offer some marginal benefits. He suggested that the threshold for assessing value of medical interventions should include whether they are proven to (1)
|
From page 29... ...
But no one would probably write a check for $6,000 a month to not lose their hair," Green said. Similarly, different chemotherapies for gastric cancer are equally effective, but have different quality-of-life issues.
|
From page 30... ...
In addition, several speakers suggested applying more appropriate financial incentives, developing and applying performance metrics, facilitating greater use of and adherence to standards and treatment guidelines, and focusing more on cancer prevention. To improve clinical practice guidelines, participants also suggested gathering more clinically relevant information about interventions as part of a learning health care system.
|
From page 31... ...
"Increasingly, we have to come to terms with that uncomfortable fact. We need the tools and the leadership from our clinicians to consider price, both financial price and broad price, as part of our shared decision making about treatment." Shankaran pointed out that cancer patients are experiencing high unexpected out-of-pocket treatment expenses because physicians often neglect to discuss the financial risks involved with their therapies and end-of-life care.
|
From page 32... ...
Both Schrag and Gruman noted that cancer patients and their families are increasingly expected to provide complicated home care, but often there is not 24-hour support for home care, such as clinicians who can give patients advice after standard office hours. "When we have good support to care for ourselves at home, we are more satisfied, we do better, and we also rack up fewer costs to the system," Gruman said.
|
From page 33... ...
When a workshop participant asked Temel if such discussions affect patient quality of life, she responded that an early palliative care study found that the majority of patients who became accurate in stating that their cancer was incurable experienced improved quality of life (Temel et al., 2011)
|
From page 34... ...
Improving Clinician Education Although physician fees comprise 15 percent of all Medicare spending, the decisions physicians make influence 80 percent or more of Medicare spending, McClellan said, making it imperative that physicians are better trained to practice high-quality, affordable cancer care. Emanuel suggested educating oncologists about the financial aspects of running a practice and making them more aware of the costs involved and how to mitigate them without compromising the care of their patients.
|
From page 35... ...
We created the world's largest epidemic of prostate cancer by screening with a very simple screening test, the prostate-specific antigen [PSA] test, without having the evidence in hand about whether it would actually help people," Kramer said.
|
From page 36... ...
Best Practices in Cancer Care Workshop participants suggested a number of changes to clinical practice that could facilitate more affordable, high-quality cancer care. These changes include • greater use of and adherence to treatment guidelines; • reducing or eliminating use of procedures with little or no value; • making care more coordinated and efficient; • improving functionality of EMRs; and • prioritizing cancer prevention.
|
From page 37... ...
Emanuel also suggested supporting insurers who only pay for cancer treatments that adhere to clinical practice guidelines, standard of care, or evidence-based treatment pathways. "We don't like to say no and be the bad guy, but we need to support insurers that say no," he said.
|
From page 38... ...
Schottinger noted that due to adherence to treatment guidelines facilitated by Kaiser's EMR system, the variation of its providers has been substantially reduced, with 90 percent adhering to protocols on the first round of therapy for cancer. Schnipper reported that when the ASCO Quality Oncology Practice Initiative (QOPI; see Box 2)
|
From page 39... ...
SOURCES: IOM, 2011; QOPI, 2013a,b. even independent of the financial incentives that we probably need as well," Schnipper said.
|
From page 40... ...
• o not use PET, CT, and radionuclide bone scans in the D staging of early breast cancer at low risk for metastasis. • or individuals who have completed curative breast cancer F treatment and have no physical symptoms of cancer recur rence, routine blood tests for biomarkers and advanced imaging tests should not be used to screen for cancer recurrences.
|
From page 41... ...
Such imaging is not likely to help the patients, will expose them to unnecessary radiation, and may yield false positive results that will require follow-up procedures, Schnipper stressed. Evidence supporting the fourth item on the list comes from two randomized trials conducted in the 1990s that compared different surveillance strategies for breast cancer patients who had completed curative breast cancer treatment and had no symptoms of recurrence.
|
From page 42... ...
These suggestions included eliminating duplicated tests and services; integrating palliative care throughout the continuum of cancer care, and improving care at the end of life; providing more efficient survivorship care; better aligning screening with the evidence base; and making greater use of nurses and other clinical specialists who are less expensive than physicians. 11See http://www.abimfoundation.org/Initiatives/Choosing-Wisely.aspx (accessed December 17, 2012)
|
From page 43... ...
Schottinger also pointed out that Kaiser clearly demonstrated that integrating palliative care physicians into the oncology clinic not only benefits patients, but also reduces costs. She added that Kaiser employs social workers because "they have more time than doctors and [may]
|
From page 44... ...
In addition, early integration of palliative care has also been shown to prolong median survival among patients with metastatic non-small-cell lung cancer (Temel et al., 2010)
|
From page 45... ...
This is an IT issue that we have to piece together," Schrag said. Aberle suggested EMRs could make lung cancer screening more costeffective by tracking and helping to manage patients so they receive the appropriate follow-up care.
|
From page 46... ...
Kaiser Permanente's EMR captures every encounter with every patient and ensures that the care patients receive at Kaiser Permanente conforms to evidence-based practice guidelines that are built into their EMR software. "That means that if you are a member who is 55 years old and you tweaked your knee and go to see your orthopedic [doctor]
|
From page 47... ...
Kaiser Permanente has used the data collected in its EMR system to modify its practice protocols. For example, it reviewed the outcomes of patients with breast cancer given docetaxel/cyclophosphamide who were older and had more comorbid conditions, such as diabetes.
|
From page 48... ...
Schottinger attributed Kaiser Permanente's successful cancer prevention efforts in part to their extensive EMRs that notify practitioners if their patients are not up to date on proper screening tests, are smoking, or are not getting sufficient exercise, for example. Evidence Base for Clinical Practice and Reimbursement Several speakers noted there is a lack information on the comparative effectiveness of cancer care interventions that can guide clinical practice.
|
From page 49... ...
Such off-label prescribing is common in oncology because of the life-threatening nature of the illness, and the biologic plausibility that what works for one type of cancer might work for a similar cancer. Furthermore, once drugs enter the market based on efficacy for a narrow group of cancer patients, pharmaceutical companies are not likely to invest in more Phase III clinical trials to broaden that use, Abernethy said.
|
From page 50... ...
Gathering Clinically Relevant Information About Interventions Limitations in the evidence base for making treatment decisions in clinical practice can inhibit the delivery of affordable, high-quality cancer care, several workshop participants stressed. "Clinicians need a method to make
|
From page 51... ...
. She also suggested developing learning health care systems that collect point-of-care data that can inform personalized medicine, comparative effectiveness, health care redesign, and high-quality cancer care (Abernethy et al., 2010b; IOM, 2010a)
|
From page 52... ...
He suggested being more rigorous about measuring clinical outcomes, such as complications, and suggested that medical practices collect data that can be used for performance metrics and evidence development. "If you can't measure it, you can't do very much to support it.
|
From page 53... ...
She suggested, however, that the accrual process needs to be improved so more patients enter the trials, noting that now roughly 5 percent of cancer patients go on a clinical trial. She also suggested designing studies with more meaningful endpoints and effect sizes and aiming for bigger benefits, rather than extending life by only 6 weeks, for example.
|
From page 54... ...
from patients in multiple practices; • ggregate information from EMRs, new clinical trials, and a published guidelines; • dentify trends and associations among myriad variables in i order to generate new hypotheses; • nable physicians and researchers to evaluate those hypoth e eses and determine which ones may lead to improved care in real-world settings; and • nable clinicians and researchers to quickly apply those e conclusions, forming a continuous cycle of learning. In practice, once the full technology platform is completed, CancerLinQ aims to • mprove personalized treatment decisions by cancer care i teams by capturing patient information in real time at the point of care; providing real-time decision support tailored to each patient and his or her cancer; and automatically report ing on the quality of care compared with clinical guidelines and the outcomes of other patients; • ducate and empower patients by linking them to their e cancer care teams and providing personalized treatment information at their fingertips; and • reate a powerful new data source for use in real-world qual c ity and comparative effectiveness studies, and to generate new ideas for clinical research.
|
From page 55... ...
Schottinger noted that Kaiser Permanente has a comparative effectiveness and safety research institute that uses the extensive information collected in EMRs. This health care system has also conducted several randomized controlled trials, demonstrating the importance of integrating palliative care services.
|
From page 56... ...
Financial Incentives Aligned with Affordable, High-Quality Cancer Care A number of speakers noted the need for better alignment of financial incentives to reward affordable, high-quality cancer care. Financial incentives can encourage both clinicians and patients to change their behavior and consider costs in decision making.
|
From page 57... ...
"We have to appreciate that whether you are a large hospital or a small hospital, a good portion of your bottom line comes from the technical fees from radiation oncology," Bekelman said. "To stop this spiral, we have to sever the relationship between treatment choice and reimbursement for treatment," Bekelman stressed, recommending that instead provider incentives be aligned toward patient-centered, coordinated care among cancer specialists, such as radiologists and medical oncologists, and primary care physicians.
|
From page 58... ...
Thus, there is more incentive for a cancer center to avoid the expense of hiring a nurse by having the care delivered by a physician. "It is a prime example of how we don't have the incentives aligned," Earle said.
|
From page 59... ...
The costs are currently running about 40 percent lower than projections with this drug plan, according to McClellan. "There are still a lot of health care costs, but they are a lot lower than they would have been according to the projections, based on traditional ways of using prescription drugs.
|
From page 60... ...
Delivery System and Reimbursement Changes Participants discussed several strategies that aim to better align financial incentives and overcome current challenges to delivering affordable, quality cancer care. These strategies include capitation, bundled/episode-related payments, accountable care organizations and shared savings, medical homes, and the application of cost-effectiveness thresholds and value-based or performance-based care.
|
From page 61... ...
For example, they were not using Avastin to treat breast cancer before FDA took it off the market for that indication because they didn't believe the evidence," Ramsey said. Episode-Related Payments Somewhat similar to capitation are bundled or episode-related payments, Bach reported.
|
From page 62... ...
In these pilots, there are financial incentives for coordinated care and providing higherquality care, including care that adheres to guidelines, and avoiding some complications, such as emergency room visits. "There are quality and other modifiers to the payment system that try to get away from this ‘more treat 13AHRQ defines the concept of a medical home as the organization of primary care that delivers the core functions of primary health care.
|
From page 63... ...
Schnipper also advocated for oncology homes as an outgrowth of medical homes in recognition that "the oncologist oversees an enormous complexity of care and care decisions." He added, "This represents a way to work towards synchronizing care in a way that provides the best outcomes for our patients." Shared Savings Plans/Accountable Care Organizations In shared savings plans, care providers are paid their traditional M edicare payments, but if they show improvement on agreed-upon measures of quality and reduce costs, they keep a portion of the savings above a certain threshold. Medicare has run shared-savings pilot projects, called Physician Group Practice Demonstrations.
|
From page 64... ...
The Pioneer ACO model is a CMS Innovation Center initiative designed to assess the impact of different payment initiatives for experienced ACOs. The Medicare Shared Savings Program is designed to reward ACOs that lower the growth in health care costs and meet performance metrics.
|
From page 65... ...
In a new payment scheme devised by Health Alliance Medical 14A multigene expression test developed to predict the risk of recurrence for nodenegative, estrogen-receptor-positive breast cancer. Oncotype DX may help identify women who are at such low risk of breast cancer recurrence that the risks of chemotherapy treatment would outweight the benefits of the treatment (IOM, 2012)
|
From page 66... ...
He noted that the Affordable Care Act includes competitive bidding for durable medical equipment, such as prosthetics and orthotics. In the first year of its operation, prices for such commodities decreased by 42 percent, he said, and the program is to be expanded throughout the country by 2016.
|
From page 67... ...
Journal of Clinical Oncology 28(27)
|
From page 68... ...
2010. New technology and health care costs -- the case of robot-assisted surgery.
|
From page 69... ...
2012. Effect of early palliative care on chemotherapy use and end-of-life care in patients with metastatic non-small-cell lung cancer.
|
From page 70... ...
2011. Patient-centered cancer treatment planning: Improving the quality of oncology care: Workshop summary.
|
From page 71... ...
2008. Cost savings associated with US hospital palliative care consultation programs.
|
From page 72... ...
2011. Brachytherapy for accelerated partial-breast irradiation: A rapidly emerging technology in breast cancer care.
|
From page 73... ...
2011. Delivering affordable cancer care in high-income countries.
|
From page 74... ...
2009. Health care costs in the last week of life: Associations with end-of-life conversations.
|
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.