ASCO is starting to address the issue of value in cancer care, “moving the needle” away from cost alone, according to Lowell E. Schnipper, MD, the Berenson Professor in Medicine, Harvard Medical School, Boston, and Chair of the ASCO Task Force on Value in Cancer Care. This is not about the absolute dollars expended, but about what these dollars buy for patients who may be experiencing financial, as well as physical, toxicity, Dr Schnipper said at ASCO 2014.
The issue is not just about cost. “Cost demeans the purpose for which we are all gathered here, which is to improve patient care,” he said, noting that the task force is focusing on “patient-centeredness.”
“We chose not to take a macroeconomic incentive, but to consider the doctor and patient, and how they are thinking about the variables that we take into account every day in cancer care,” he added.
Dr Schnipper referred to the concepts put forth by Michael E. Porter, Bishop William Lawrence University Professor at Harvard Business School, and a leading proponent of value-based care: value should be defined around the customer. The creation of value for patients determines “the rewards” for all other actors in the healthcare system, and the success of a value-based treatment is measured through outcomes, not by the volume of services delivered.
“Porter makes the point that patient-centeredness is one of the key elements as we think about the value equation,” he said. “It’s appropriate for a physician to use all health-related resources in an appropriate manner that is resource-efficient. This implies doing our best for our patients, and understanding that doing so will positively impact the body politic.”
Variables Affecting Value
The Task Force on Value in Cancer Care has identified 5 common practices that are not evidence-based, and it recommended that they not be routinely used. These 5 elements include:
- Unwanted variation in quality and outcome
- Harm to patients
- Waste and failure to maximize value
- Health disparities
- Failure to prevent disease.
The Quality Oncology Practice Initiative should help reveal the degree of variation in clinical practice, which ties into safety. Experimental models of payment reform are being tested.
Usable Tool for Oncologists
The goal is to create a transparent, clinically driven, methodologically sound method for defining and assessing the relative value of care options in oncology, which ultimately would “drive change” among payers and industry and encourage the promotion of high-value care, Dr Schnipper said.
“We want to give oncology providers the skills and tools to assess the relative value of therapies, and use these in discussing treatment options with patients,” he said. The tool would describe the different clinical scenarios, treatments, benefits, toxicities, and costs related to cancer care and ascribe each treatment as having no value, low value, medium value, or high value. In patients with non–small-cell lung cancer (NSCLC), for example, the value parameters will include treatment regimen, median overall survival (OS), hazard ratio, progression-free survival, palliative data, time to next treatment, toxicity, and the total cost of care.
For example, for the first-line treatment of NSCLC, carboplatin plus paclitaxel yields a median OS of 8.2 months and costs $374; cisplatin plus pemetrexed offers 10.3-month survival and costs $6183; the combination of paclitaxel, carboplatin, and bevacizumab results in a 12.3-month survival and costs $8329.
“We are wrestling with data like these to provide a value system that would provide some degree of nuance and distinguishability among regimens,” Dr Schnipper said.