Reducing the Costs of Cancer Might Involve 'Physician Heal Thyself'

To reduce the costs of cancer, two oncologists from The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University think a solution might rest with providers themselves. They argue that community oncologists should do their part to increase the use of evidence-based treatments, standardize care with pathways, transition away from fee-for-service to alternative payment methods, and change communication with patients about reasonable end-of-life care.

In their article, "Delivering Maximum Clinical Benefit at an Affordable Price: Engaging Stakeholders in Cancer Care," Ronan J. Kelly, MD, and Thomas J. Smith, MD, propose three means by which total cancer care costs could be reduced while causing the least harm: improve end-of-life care, reduce imaging use, and reduce drug prices.

According to the authors, care at the end of life is expensive and sometimes ineffective. They note that in the last year of life the amount spent can be close to 25% of total Medicare costs. It gets even more expensive in the last month of life, when 10% of the total Medicare budget is spent.

Oncologists should limit expensive imaging to situations in which there is strong evidence of benefit. Kelly and Smith note that even for lymphoma, the cure rate from salvage chemotherapy is just as good if the disease is diagnosed from clinical findings as from a routine surveillance PET scan.

Value-based drug pricing requires a dialogue between oncologists and their patients about the cost of care. ASCO recommends that oncologists discuss the cost of care with patients, but most oncologists do not know the costs, and many do not feel adequately trained to have cost discussions with patients. Patients and families nearly always want this information but cannot get it from their oncologists.

The authors also offer models and examples that seem to preserve and maintain quality while reducing costs. They cite the Veterans Administration and Kaiser Permanente as two health systems that provide high quality care with significant cost savings.

Medical homes or patient-centered medical homes are another model in which care is delivered by a team led by an oncologist along with other practitioners such as nurse practitioners. In the medical home setting, full care is provided for a set fee. These facilities provide comprehensive care with information fully shared across all the providers, adherence to set performance measures such as pathways, and a bundled payment system (one fee that includes all the services). The authors highlighted one oncology practice consisting of nine doctors that adopted the medical home model. This led to a 68% reduction in emergency department visits, a 51% reduction in hospital admissions, and US$1 million saved per physician per year.¹

The authors conclude that what’s needed for a fair and equitable cancer system is “political leadership working together with oncologists and patients to explicitly address the issue of what value is needed to justify expensive treatments.”

The article is published in the February 14 issue of The Lancet Oncology.

References:

• Kelly RJ, Smith TJ. Delivering maximum clinical benefit at an affordable price: engaging stakeholders in cancer care. Lancet Oncol. Published online February 14, 2014
• Sprandio JD. Oncology patient-centered medical home. J Oncol Pract 2012; 8 (suppl): 47s—49s.