After gathering at an Institute of Medicine workshop about the rising costs of cancer care, a group of prominent oncologists became so concerned that they issued a call to action in The New York Times (3/23/2013).
“People who were there were very, very alarmed,” said Patricia A. Ganz, MD, Director of Cancer Prevention & Control Research at UCLA's Jonsson Comprehensive Cancer Center and the co-chair of the workshop. “From a societal perspective, we cannot continue to expend resources like this. It's not just doctors—we need to all work together. That's really the message: Collaboration with all stakeholders is absolutely critical.”
She was one of more than 20 oncologists who signed the essay, “A Plan to Fix Cancer Care,” written by Ezekiel Emanuel, MD, Vice Provost for Global Initiatives and Chair of the Department of Medical Ethics and Health Policy at the University of Pennsylvania, and a regular contributor to the Times' opinion pages.
Another signatory, Otis Brawley, MD, Chief Medical Officer of the American Cancer Society, said the column's goal is to build a consensus about the scope of the cancer cost crisis.
“There's a large number of people, especially in the survivor community and the advocacy community, who just don't understand there is this serious problem,” he said. “There are some people in medicine—good people in medicine, not just the people who want to take advantage of the system—who don't understand it.”
Beyond that, Brawley says the public must be educated that even though the “whatever it costs” mentality threatens to bankrupt the U.S. economy, it is not buying the world's best health care.
“People need to realize that the quality of care in the United States is actually not necessarily as great as many people think it is in comparison to other countries in western Europe,” he said. “By 2037, we are destined that a quarter out of every dollar spent in the U.S. will be spent on health care. And our outcomes are just not justifying that amazing expenditure.”
About half of personal bankruptcies stem from medical debts, but most oncologists cannot tell patients what their treatment and related health care services will cost, said Thomas J. Smith, MD, Director of Palliative Care for Johns Hopkins Medicine and the Hopkins' Sidney Kimmel Comprehensive Cancer Center.
“Some of my families come to me and say 'I appreciate that my wife is doing well, but we are getting bills for $13,000 a month, and the 20 percent co-payment is impossible. What does the future hold?”
The plan described in the essay stemmed from a National Cancer Policy Forum workshop, “Delivering Affordable Cancer Care in the 21st Century,” held last fall (OT, 11/20/12 issue). The workshop was convened in part to inform deliberations of an IOM consensus committee, “Improving the Quality of Cancer Care: Addressing the Challenges of an Aging Population,” which Ganz chairs.
The New York Times essay calls for five major changes:
- Fee-for-service needs to be replaced by bundled payments, in which all physicians who treat a patient would divide a single payment.
- Insurers must give physicians information about where they are spending money. Although it is well-known that the costs of treatments and tests vary considerably for patients with identical cancer, oncologists themselves generally have no information about how their diagnostic and treatment choices add up.
- New payment methods must be monitored for quality to make sure there is neither under- nor over-utilization.
- More oncology practices should adopt “high touch” protocols in which nurses manage common symptoms to avoid the need for emergency department visits and hospitalizations and where end-of-life planning and palliative care are standard.
- Research incentives need to be realigned so that expensive tests and treatments are not allowed to proliferate without evidence that they improve survival or reduce suffering. For example, the authors point to 800,000 robotic surgeries, mostly for cancer, performed in the past two years although there is no reliable evidence of improved survival or reduced side effects.
By 2030, more than 70 percent of patients with cancer will be eligible for Medicare, meaning that the federal government will be primarily responsible for paying for their care. For that reason, Emanuel and his co-authors want U.S. Health & Human Services Secretary Kathleen Sebelius to convene a group of representatives from Medicare, private insurers, oncologists, quality experts, and patients to figure out how to implement the plan.
Although many of the signatories are leaders in medical societies, that does not imply that any organization is behind the plan, said Lowell E. Schnipper, MD, Chair of the American Society of Clinical Oncology's Cost of Cancer Care Task Force and Chief of Hematology/Oncology at Beth Israel Deaconess Medical Center.
“ASCO has not endorsed this at all. To my knowledge, no professional organization has. A group of professionals who care about the issue came together, and after lots of massaging of the text, came to a point where all of us found some level of agreement with what's there.”
The idea of a surgeon, a medical oncologist, and a radiation oncologist sharing a single payment for a patient's cancer treatment seems foreign in today's highly fragmented health system. But bundled payments for health care services are gaining traction through dozens of pilot programs currently under way—in part because they incentivize physicians to coordinate care and choose treatments that provide the best patient outcomes at the lowest cost.
Ganz says the bundled-payment concept is similar to the diagnosis-related groups (DRGs) that are used to pay for hospital care or the package billing used for transplantation and some other complex services: “Just think about when DRGs came in for hospitalizations. Everybody said, ’How are we going to live with that?’ Well, financially, hospitals have survived,” she said.
Exactly how bundled payments for cancer care would work best has yet to be determined.
A single payment for a disease state—say, Stage II breast cancer—would remove the financial incentive to provide services that have questionable value. “This would get us out of the [the idea that] everyone has to have a PET scan,” Smith said. “PET scans are essential in lung cancer but as for superiority in outcomes in other cancers—show me the data.”
In a few experiments with bundled payments for cancer care, the “bundle” has been narrowly defined, such as all episodes of chemotherapy administration for a given disease state. Justin Bekelman, MD, a radiation oncologist and health services researcher at the University of Pennsylvania's Abramson Cancer Center, believes there may be a more comprehensive approach:
“Will we improve cancer care and accrue more cost savings by incentivizing better care coordination amongst the specialties? One way to examine that is to test innovative payment reform models, including bundled payments, to promote smarter and more effective coordination among cancer physicians, surgeons, primary care providers, and others providers—and then measure the outcomes and costs,” he said.
Bekelman, a signatory to the Times' essay, and two colleagues recently proposed the concept of Cancer Care Groups (CCGs) (JAMA Intern Med, published online ahead of print 4/29/13, doi:10.1001/jamainternmed.2013.635). A CCG would include panels of surgical, radiation, and medical oncologists who provide comprehensive care throughout a patient's illness, coordinating with primary care physician and palliative care specialists when needed.
The CCG would receive a single payment for each patient, based on diagnosis and stage, risk adjusted for disease severity and comorbidities, and adjusted for local cost of living. Most importantly, the payment would be linked to clinical guidelines to protect against skimping on care.
“This bundled payment approach will reduce cost growth through incentives for cancer specialists to discontinue unnecessary or discretionary tests and therapies and to shift to lower-cost but still equivalent and effective therapies,” Bekelman wrote.
What to Do Now
One of the plan's tenets—the need for more “high touch” cancer care—speaks specifically to oncology practices.
“Many of us believe that we could deliver a better quality of integrated care by having the appropriate physician and non-physician personnel working out of the same organizational complex, caring for patients in a 24/7 manner,” Schnipper said.
“That enables anxieties to be addressed when that's an issue, pain to be addressed when that's an issue, and an appropriate transition to palliative care when and if that becomes necessary. That would be a very positive departure from the way that much of cancer medicine is practiced.”
The plan's coauthors want insurers to pay for nurse-initiated symptom management, care coordination, and end-of-life planning, all of which can reduce high-cost emergency department and inpatient use, redundant tests, and futile treatments.
Ganz said she fears that only a minority of oncology practices are organized to systematically assess symptoms and address them proactively. She wants to see patients' reports of their symptoms routinely collected—and protocols ready to address each symptom.
“If the patient is having pain, if the patient is having insomnia, if the patient is having fatigue, you can address these with evidence-based practices,” she said. “But they are not typically assessed, and they are often ignored, and patients suffer. And of course, if someone is suffering, they may wind up in the hospital unnecessarily.”
Meanwhile, Smith encourages oncologists to initiate end-of-life planning discussions with their patients long before their death is imminent, giving them an opportunity to make decisions about treatments, palliative care, and hospice services.
“Our patients want real prognostic information, not just 'this has a 50 percent chance of working,' which means 'shrink the cancer' to us but might mean 'cure the cancer' to someone else. People want to know what's the average-case, the best-case, and the worst-case scenario,” he said.
“And some of our studies have shown that patients really want us to bring up advance care planning and advance directives. So we can remind ourselves to do these tasks, which aren't always pleasant to think about but are pretty rewarding once we get there.”
While improving the care delivered by individual practices can help make cancer care more sustainable, broad changes to all elements of cancer care research, delivery, and payment are needed, Brawley said. He wants oncologists to support the five-point plan and to encourage their Congressional representatives and others in the cancer care world to do so.
“Quite honestly, if we continue as we have, oncology is not going to be financially viable within the next 10 to 15 years,” he said. “The economy simply cannot support what we've been doing.”
iPad Exclusive! Implications for Palliative Care
Podcast Interview by Lola Butcher
Listen on the iPad edition of this issue to hear Thomas J. Smith, MD, Director of Palliative Care at Johns Hopkins Medicine and the Hopkins' Sidney Kimmel Comprehensive Cancer Center, who is one of more than 20 prominent oncologists who signed the “A Plan to Fix Cancer Care” essay that appeared in The New York Times a few weeks ago. The essay was written by Ezekiel J. Emanuel, MD, an oncologist who serves as vice provost and professor at the University of Pennsylvania. In this audio interview Smith discusses the essay's implications for palliative care.
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An Advance Care Planning Script to Use at Transition Points
Thomas J. Smith developed the following “script” to use to help initiate an end-of-life planning discussion with patients:
“If we are thinking about second or third chemotherapy, there are some other important issues to address at this time, while you are still relatively well.
Since this is such a serious illness, and nearly all people die within a year, many people use this time to address a life review. That would include what they have learned during life that they want to share with their families, and planning for events in the future like birthdays or weddings.
Some people address spiritual issues.
Some people address financial issues like a will.
Some people address Advance Directives (Living Wills). For instance, if you could not speak for yourself, who would you want to make decisions about your care? If your heart stopped beating, or you stopped breathing, due to the cancer worsening, would you want to have resuscitation (CPR), or be allowed to die naturally without resuscitation?
Some people use this time to discuss with their loved ones how they would like to spend the rest of their life. For instance, how and where do you want to spend your last days? Do you want to have hospice involved?
These are all difficult issues, but important to discuss with your family and your health care professionals.”