The Complexity of Value: Weighing Perspectives of Various Stakeholders

The Complexity of Value: Weighing Perspectives of Various Stakeholders

Although the cost and value of health care is an issue facing the United States as a nation, there are a wide variety of viewpoints and opinions that must be considered when examining the issue as a whole and how it relates to cancer specifically. ASCO is highlighting this important issue during Friday’s Extended Education Session, “Can We Find Common Ground? Stakeholder Perspectives on Value in Cancer Care,” to be held 3:45 PM-6:00 PM, S100a.

Attendees will be exposed to viewpoints on value from experts representing the opinions of oncologists, patients, payers, and industry.

“There are many stakeholders and interests in our health care system that bear on the treatment that patients receive, including not only what the physician recommends, but also the influence of payers, the producers of new innovations, and the goals and expectations of patients themselves,” said session Chair Neal J. Meropol, MD, of Case Western Reserve University. “Although there are clearly shared goals with regard to improving the health of our patients, each constituency has its own perspectives and its own motivations. Therefore, it has become critical that these stakeholders are able to find common ground so that patients are assured of having access to high-value cancer care and to ensure that the pipeline of new innovations is robust.”

Problems Surrounding Value in Cancer Care

Dr. Meropol will open the Extended Education Session by framing the discussion for attendees. He will review health care costs at the societal level and drill down to the level of cancer care to frame the problem as it relates to patient access and patient decision-making about therapy.

At its simplest formulation, value represents the relationship between the benefits of an intervention and the cost of that intervention. During the past decade, there has been an explosion in the cost of new cancer diagnostics and treatments. This increase has raised questions regarding whether the growth in health care costs overall and related to cancer in particular is sustainable.

“As a society, our spending on health care represents a substantial proportion of our entire economy,” Dr. Meropol told ASCO Daily News. “Although we spend more on health care in the United States on a per capita basis than all other industrialized countries, it is debatable to what extent health outcomes in the United States are superior.”

According to the Organisation for Economic Cooperation and Development Health Statistics 2013, the United States spent approximately 18% of its gross domestic product on health care in 2010, a number that is greater than many other industrialized countries.1 In addition, the national health expenditures per capita on health care in the United States have increased dramatically according to data from the Centers for Medicare and Medicaid Services from approximately $1,000 per person in 1980 to approximately $8,900 per person in 2012.2

The question is whether Americans are getting a good value for their dollar. Current estimates place American’s life expectancy as similar to that of countries spending half as much on health care.

When looking at cancer specifically, research has shown that there is a rising cancer burden in the United States as the generation of baby boomers ages. Although the cost of cancer care is only a small proportion of health care expenditures, the out-of-pocket burden for patients is growing.3

“Patients are increasingly making decisions based not only on the potential benefits of therapies, but on their out-of-pocket expenses,” Dr. Meropol said. “Given that new innovations in cancer care routinely cost in excess of $100,000 per year, sometimes with modest benefits, oncologists should be at the forefront of a discussion about value in health care.”

Defining Value as an Oncologist

Lowell E. Schnipper, MD, chief of hematology/oncology at Beth Israel Deaconess Medical Center, will be discussing value from the point of view of the oncologist and will also highlight some of the many initiatives that ASCO is undertaking to help guide its members in addressing this issue.

One of the most long-standing efforts that ASCO has made is educating oncologists through its clinical practice guidelines. These published guidelines are designed to provide practicing oncologists with guidance on treatments so that patients receive gold standard treatment. Moving forward, ASCO is beginning to incorporate cost information into its guidelines in order to help clinicians provide and consider this critical information when making treatment decisions.

“Many patients are afflicted with policies that force large copays, and we know from experience that bankruptcy is often initiated by medical debt,” Dr. Schnipper said. “We need to help patients understand cost and their options for care, and put those options in context.”

“Patients are increasingly making decisions based not only on the potential benefi ts of therapies, but on their out-of-pocket expenses.”

— Dr. Neal J. Meropol

ASCO also believes that oncologists have to advocate for their patients and publically demand that health care costs be curbed where possible. Teaming with the American Board of Internal Medicine Foundation, ASCO has now published two Choosing Wisely® Campaign lists that highlight treatments or procedures for which common use and clinical value are not supported by available evidence.4

“We understand that high quality is the coin of the realm,” Dr. Schnipper said. “ASCO is reinforcing that message with a refocused effort on value in its Value in Cancer Care Task Force.”

In 2007, ASCO developed its Cost of Cancer Care Task Force, now known as the Value in Cancer Care Task Force, to begin to provide its members with resources that can help to integrate financial considerations into their patient discussions.5

Among its many initiatives, the Task Force is working on developing an algorithm or framework to help its members define value, Dr. Schnipper said. This framework will consider clinical benefit of a treatment, that treatment’s toxicity or side effects, and its cost or “financial toxicity.”

Ultimately, ASCO hopes that the consideration of these three elements will determine a value “score” for treatments, and that this score will help oncologists when weighing treatment options for patients.

Balanced Perspectives

The perspectives presented at the Extended Education Session will be rounded out by three additional speakers.

Diane Blum, MSW, former editor-in-chief of and a member of ASCO’s Value in Cancer Care Task Force, will discuss the patient perspective on value, which she said is a perspective that is under-represented in the research literature.

“I have spent my career with a strong focus on the barriers to people with cancer getting the best care,” Ms. Blum said. “First and foremost, among those barriers is the area of money, cost, and finances.”

When considering the patient perspective on value, physicians must consider each individual, Ms. Blum said. She emphasized the importance of talking to each patient, finding out what is important to them, and what their values are. Physicians need to not only discuss additional treatments and their costs, but also topics such as logistics. What will it mean to undergo this treatment? How often will they need to come of the hospital?

“In addition, people often value different things when they are early in their diagnosis compared with later on when they may be more sick,” she added. “Patients want to participate in ongoing, informed medical decision-making, and that needs to be a two-way conversation.”

Ms. Blum acknowledged that this can be a time-consuming and difficult process, and that often prescribing additional treatment may be the easiest decision. However, during her presentation she will discuss how crucial these conversations are and present some tools for opening up communication on value.

In addition to the out-of-pocket costs faced by patients, there is a disproportionate weight on insurers and on public payers, in that the burden of paying for cancer care is higher than that of other diseases. Lee N. Newcomer, MD, MHA, senior vice president of oncology services at UnitedHealthcare, will present information on the payer perspective on value and new models of insurance design that might promote higher value and improved outcomes.

Among the topics that Dr. Newcomer will address during his presentation is the idea of a payment strategy based around predefined treatment approaches as outlined by representative bodies of physicians. For example, UnitedHealthcare uses treatment guidelines issued by the National Comprehensive Cancer Network (NCCN) to determine their coverage.

“We decided that if the NCCN recommended a drug for cancer then we will cover it,” Dr. Newcomer said. “But, if the NCCN does not recommend that drug, then we do not provide coverage.”

Over time the selections may be narrowed if comparative effectiveness studies show that some treatments are more effective than others.

The industry perspective will be presented by Gregory P. Rossi, PhD, vice president of payer evidence at AstraZeneca UK. He will discuss the cost of developing cancer therapeutics, highlighting the goals, challenges, and responsibilities of the people that drive new innovations in the oncology arena.

“Patients want to participate in ongoing, informed medical decisionmaking, and that needs to be a two-way conversation.”

— Ms. Diane Blum

Changing Role of Oncologists

Finally, Ezekiel J. Emanuel, MD, PhD, of the University of Pennsylvania, will round out the session with a discussion on how oncologists should begin to become value-based providers.

“I want attendees to begin to think about value, but also how to think about changing their own practice,” Dr. Emanuel said.

During his presentation, he will address the principles of ethics that should underlie oncologists’ approach to applying judgments of value in the care of individual patients. In addition, he will address the roles and responsibilities of oncologists in addressing problems associated with the rising cost of cancer care.

Learning to Consider Value

At the end of this session, attendees should come away with a better understanding of how to assess value and some of the resources available to them as they begin to incorporate the question of value into their everyday practice.

“As physicians, we need to recognize that not all treatments and diagnostic strategies have equal value, and it is becoming increasingly important that we are prepared to help patients weigh the value of different options so they can make the best choice for themselves,” Dr. Meropol said. “We hope that attendees will leave with a highly nuanced understanding of the issues surrounding the cost of cancer care so that they will be comfortable addressing value both at the bedside and at the policy level.”