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A seismic shift is occurring in how physicians calculate the value of cancer care. For decades, the merits of a given intervention were often measured primarily using overall survival gains, with even a few months of arrested cancer progression lauded as a major advance. Although some trials still tout such gains as the gold standard, researchers and policy makers are increasingly looking to expand the list of variables—many of them focused on quality of life and other functional outcomes—that need to be included when measuring the true value of cancer treatment.
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November 2015ENTtoday spoke with head and neck surgeons and other experts who are at the forefront of such efforts. Whether it’s a groundbreaking switch away from fee-for-service medicine to a bundled care model aimed at reducing waste while maintaining quality, or healthcare policy statements encouraging physicians to emphasize quality of life and other patient-focused, longer-term endpoints, the physicians behind these initiatives are changing the national dialogue about how we should define—and deliver—value for patients who have a wide variety of malignancies.
The timing of such efforts is not accidental. Recent projections of the cost of cancer care in the United States are staggering. By the year 2020, it is estimated that cancer treatments will cost more than $200 billion annually, according to data from the National Cancer Institute, with head and neck cancers expected to account for nearly $2 billion of that projected spending.
Unbundling the Waste in Cancer Care
The United States’ predominant fee-for-service payment model—in which providers are paid for every office visit, test, and treatment—is often cited as the chief culprit in soaring healthcare spending. That’s partly why an alternative system is being piloted at the University of Texas MD Anderson Cancer Center in Houston.
The pilot, a collaboration between MD Anderson’s Head and Neck Center and UnitedHealthcare (UHC), uses bundled payments as the basis for reimbursement. Under the bundled payment system, providers are paid for a defined episode of care with a single negotiated fee. Proponents say this approach incentivizes the elimination of wasteful tests and procedures and instead challenges physicians to provide care that is laser-focused on achieving the highest quality clinical care at the lowest cost.
MD Anderson appreciated the value of such an approach after seeing it in action in an earlier pilot of breast, colon, and lung cancer that slashed the cost of care by a third while improving key clinical outcomes (J Oncol Practice. 2014;10:322-326).
To date, approximately 50 patients are enrolled in the three-year bundled payment pilot program, and “so far the data look very good,” said Randal S. Weber, MD, professor and chair of MD Anderson’s department of head and neck surgery. “For example, in our major surgical cases with reconstruction, our average length of stay [LOS] is just shy of eight days. That’s well below the national norm of around 10 to 13 days. So already, we are beginning to show that we can deliver highly efficient and effective head and neck cancer care with a lower rate of complications, as shown in the reduced LOS numbers.”
The pricing component of the bundled care model at MD Anderson also looks very promising, Dr. Weber stressed, adding that the center negotiated pricing for eight head and neck cancer bundles based on decades of research and clinical experience. “We did our homework,” he said. “We spent a great deal of time analyzing our costs for these procedures, and we set a price point for the bundles accordingly—one that we are very comfortable with. And so is UHC; this was a negotiated process. We know we’re not going to take a haircut, and UHC knows they’re not overpaying for the high-quality services we are providing to their covered patients.”
Dr. Weber said he had some initial concern that switching to a bundled care model might interfere with the many clinical research trials underway at MD Anderson. But in actuality, “UHC has been visionary in this regard,” he said. “They understand that large centers have to conduct clinical research. So if we have an approved protocol and it is deemed to be accepted cancer care, they’ll allow those patients to be on the bundle.”
Why is being research-friendly such an important part of the bundled payment pilot? “It’s the clinical trials that ultimately change guidelines-based therapy,” Dr. Weber stressed. “That flexibility is a huge win-win for us and our patients.”
As for next steps, Dr. Weber said that an expanded bundled payment model could be used “to economically profile an individual physician or treatment team that is risk-adjusted based on their patient population,” he said. “Your patients may be sicker than my patients, but with risk adjustment we can remove that degree of variability by factoring it into the value equation.”
Adjusting for risk, negotiating prices, partnering with payors—is this really in the comfort zone of most physicians? “It has to be, at least for some of us,” Dr. Weber said, “because that $200 billion price tag for cancer care in this country is simply not sustainable,” and keeping the traditional fee-for-service model is a prescription for reaching that dubious goal, he noted.
In Dr. Weber’s view, this focus on value in cancer care actually does not have to be a dry, actuarial affair.
“Where all of this comes back to me personally is the fact that we are all someday going to be patients,” he said. “Hopefully it’s not cancer, but at some point in our lives most of us are going to need the services of a physician for a fairly serious illness. And I think we would all want the highest quality care that can be delivered at the lowest cost. I’m just not sure, as a nation, that we’re there yet. But the bundling initiative and others like it, hopefully, will move us closer to that goal.” (For more information on this initiative from MD Anderson and United Healthcare, see “Bundled Up” on p. 26 of the September issue of ENTtoday.)
A New Generation of Value-Oriented Physicians
Benjamin Roman, MD, MSHP, an assistant attending surgeon in the head and neck service at Memorial Sloan Kettering Cancer Center in New York, could be viewed as a generational bookend to Dr. Weber. Fresh out of a head and neck surgery fellowship that included time for earning a master’s degree in health policy research, Dr. Roman, who recently embarked on his surgery career, is doing so after publishing a paper that seeks to help define the way the medical profession measures value-driven care in head and neck cancer (Curr Oncol Rep. 2015;17:424).
Dr. Roman’s primary strategy, as set forth in the paper, is for otolaryngologists to focus on elements of the value equation that they can directly control, “and that starts with the elements that make up the quality of care,” he said.
We have to stop focusing primarily on survival or even short-term quality of life. Rather, the focus also needs to be on functional outcomes, recovery, sustainability of that recovery, and the lasting impact that a given treatment can have on a patient’s daily activities.—Jonas A. de Souza, MD
One effective means for boosting quality is to follow established clinical pathways for head and neck cancer surgery, he noted. Such tools “are a great way to hone in on the sequence, timing, and completion of all the complex steps inherent in most head and neck cancers,” Dr. Roman explained.
Studies have shown that following clinical pathways can dramatically improve the quality of care. Dr. Roman cited two studies, conducted at the University of Pennsylvania and MD Anderson Cancer Center, showing that when clinical pathways for a variety of head and neck cancers were followed, post-operative LOS and median costs of care both fell significantly (Otolaryngol Head Neck Surg. 1999;121:755-759; Arch Otolaryngol Head Neck Surg. 2000;126:322-326).
Conversely, when clinical pathways are not followed, there is a trend towards poorer clinical outcomes. Dr. Roman pointed to a representative study by Carol M. Lewis, MD, MPH, and colleagues at MD Anderson, which looked at factors that might explain why patients who were referred to a tertiary care center for recurrence or disease persistence after definitive head and neck cancer treatment had not adequately responded to prior therapy. The researchers found that more than 40% of those patients had not been given National Comprehensive Cancer Network (NCCN) guideline-compliant care prior to their referral (Arch Otolaryngol Head Neck Surg. 2010;136:1205-1211).
“It should be noted that our results do not reflect the rate that community-based head and neck care deviates from NCCN guidelines,” stressed Dr. Lewis, an assistant professor in MD Anderson’s department of head and neck surgery. “Those data are as yet unknown. However, it does indicate that when head and neck cancer does not comply with NCCN guidelines, that may [result in] disease recurrence or persistence.”
Dr. Lewis said better adherence to guidelines is only one strategy for adding value to head and neck cancer. She also advocated more widespread use of ancillary services, such as those focused on speech pathology. Specifically, she urged clinicians to monitor patients’ ability to swallow post-surgery and provide exercises and assistance before and throughout treatment, “as opposed to when problems are recognized.” The goal, she explained, is “to limit the overall cost of treatment by limiting long-term morbidity and maximizing patient function throughout and after treatment.”
Dr. Roman agreed that having head and neck surgeons work with speech pathologists and other ancillary support service providers can boost value. That type of multidisciplinary care “is crucial—especially in cases of complex head and neck surgery requiring a big ablation and microvascular free-flap reconstruction, where post-operative functional sequelae are a key outcome,” he said.
He added that the literature supports such an approach. Studies have shown, he said, that integrated care improves a wide variety of patient-focused outcomes, including shorter wait times, better nutrition assessments and smoking cessation counseling, and, perhaps most importantly, better adherence to guideline-based care such as chemoradiation for advanced disease (Am J Otolaryngol. 2013;34:57-60).
Peri-operative complications are another quality variable that head and neck surgeons can have more control over—provided the focus is on the resulting long-term outcomes. Dr. Roman said the specialty is beginning to examine such outcomes, thanks in part to the ongoing work of the American Head and Neck Society (AHNS) Quality of Care Committee, which is in the midst of an effort to establish a head and neck surgery-specific quality reporting database.
Another Vote for Value
Dr. Roman’s emphasis on functional patient outcomes echoes the approach taken by Jonas A. de Souza, MD, an assistant professor of medicine at the University of Chicago Medicine and Biological Sciences. Dr. De Souza, a surgeon medical oncologist, advocates a value framework that balances survival, toxicities, cost, and other variables from the patient’s perspective.
“We have to stop focusing primarily on survival or even short-term quality of life,” Dr. de Souza told ENTtoday. “Rather, the focus also needs to be on functional outcomes, recovery, sustainability of that recovery, and the lasting impact that a given treatment can have on a patient’s daily activities. To date, I’m not sure our profession has been doing a great job of giving all of these variables the weight they deserve.”
The good news is that there are several strategies for rebalancing the value equation back to the patient, Dr. de Souza stressed in a recent paper (Am Soc Clin Oncol Educ Book. 2014:e304-9). One strategy he advocates, although it still needs further study, is de-escalation of potentially toxic
chemotherapies in patients with head and neck cancers who are positive for human papillomavirus (HPV). Studies have shown that such patients have a type of oropharyngeal cancer that responds better to chemotherapy than HPV-negative oropharyngeal cancer does. Thus, he noted, efforts to de-intensify treatments for HPV-positive patients are underway, with the goal of minimizing treatment-related toxicities (J Clin Oncol. 2013;31[suppl;abstr 6005]).
“If we can reduce toxicity and improve functional outcomes while providing a similar survival benefit [using de-escalation], that’s going to result in lower overall costs to the healthcare system,” Dr. de Souza said. “But it’s not going to happen unless clinicians start taking that longer, patient-focused view when choosing a given treatment regimen.”
Dr. de Souza noted that otolaryngologists are not the only ones advocating a more patient-focused approach to creating more value in cancer care. He pointed to a recent initiative by the American Society of Clinical Oncology (ASCO) to publish their own value framework in cancer care (See “An Update on the ASCO Value Framework,” p. 8), “and it is noteworthy for its focus on all of these other patient-oriented domains that are so important.”
Dr. Roman agreed that the work of ASCO, coupled with the bundling effort of MD Anderson, is an encouraging trend for the profession.
“Make no mistake—as time goes on, there will be increasing pressure on head and neck surgeons to measure the quality and value of the care we provide,” he said. “The earlier we get in the game, the more ownership we will have over how that care is measured, instead of someone else telling us how that should play out.”
David Bronstein is a freelance medical journalist based in New Jersey.
An Update on the ASCO Value Framework
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Early results are in on the groundbreaking initiative by the American Society of Clinical Oncology (ASCO) to create a conceptual framework for calculating the value of cancer treatment options.
The tool was announced in late June and published in the Journal of Clinical Oncology (published online ahead of print June 22, 2015). The paper describes how the proposed calculation tool could be used in clinical practice. Providers would use the tool to give patients a detailed accounting of the expected out-of-pocket and drug acquisition costs associated with a given treatment under consideration, along with a net health benefit (NHB) score. NHB represents the added clinical benefit that patients can expect to receive from the treatment, when compared with the current standard of care. The framework tool is based in part on elements of care quality, efficiency, and cost set forth by the National Academy of Medicine.
“We’ve received more than 400 responses since the comment period for the framework ended on August 21,” said Lowell E. Schnipper, MD, FASCO, chair of the ASCO Value in Cancer Care Task Force, which spearheaded the project. “Although lots of commenters suggested we tweak certain elements of the formula, the vast majority congratulated us for tackling an incredibly thorny problem,” he said in an exclusive interview with ENTtoday.
Dr. Schnipper, who is the Theodore W. and Evelyn G. Berenson Professor in the department of medicine at Harvard Medical School and chief of hematology/oncology and clinical director at Beth Israel Deaconess Medical Center Cancer Center, both in Boston, offered more details on the type of feedback received.
Some commenters suggested that the ASCO framework tool should record length of survival in absolute terms or years, “because if you have a doubling of survival in an aggressive disease with a very short natural history, that could still leave the patient with a very short time from which they are benefitting, versus someone with a much longer course or time-frame,” Dr. Schnipper said. In such a case, “the absolute differences in time become much more important, and we need to account for that.”
Commenters also suggested tweaks to how the tool calculates toxicity, so that “we’re not just counting all toxic reactions equally,” he noted. “Rather, we should be taking points of score away from very disabling reactions, as opposed to penalizing for those that aren’t very troublesome.”
Dr. Schnipper said such comments “weren’t a total surprise,” given the fact that the developers knew that the method used to craft the value framework has some limitations, including how the NHB scoring components were weighted. But the tool’s unwieldy format is perhaps its most serious drawback, he noted.
“What we published is very cumbersome and certainly not practical, in its current form, to talk to the patient about something so complicated,” he said. “But like many things in the digital age, complicated algorithms can be reduced via software to relatively simple technological measures. So we are likely going to issue an RFP [request for proposal] asking software developers to convert our complicated system into something that is quite user-friendly for both patients and providers.”
Those refinements notwithstanding, what has the publication of the ASCO value framework succeeded in doing with regard to the debate over value in cancer care?
“Our hope is that it has pointed to a better way of discussing treatment options with our patients,” he said, citing patients with aggressive, advanced cancer as an example. “They may know they are going to die from their disease and that there may be some new targeted—and often very expensive—treatment that may delay that by a few months,” Dr. Schnipper said. “But to them, relief from symptoms—quality of life, if you will—may be far more important than overall survival. Well, without some type of tool that triggers a conversation about what that patient truly values, what’s the chance that a cancer regimen that fully factors in their needs is going to be suggested?”
“We need to be able to develop a tool that can be used at the interface between the physician and the patient, to help ensure those conversations are taking place in a streamlined, reproducible, and humane fashion.”—DB