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Experts Weigh In on Controversial Issue of Determining Value of Cancer Care at NCCN Conference
A roundtable led by Clifford Goodman, PhD, at the NCCN 14th Annual Conference, presented various views on “Finding and Achieving Value in Cancer Care.” The panel of experts tackled the spectrum of issues related to defining value, and the concern that the benefit to patients of some of the latest cancer treatments may not warrant their costs.
March 16, 2009
HOLLYWOOD, FL — Oncology is an area of rapid growth, both in terms of technological innovation and costs in cancer care and treatment. Collectively, concerns about the balance between clinical benefit and escalating costs have been framed as questions of health care “value.” At the National Comprehensive Cancer Network’s 14th Annual Conference, Clifford Goodman, PhD, of the Lewin Group, led an engaging roundtable debating the definition, measurement, and application of value in oncology.
Panel participants Stephen Edge, MD, of Roswell Park Cancer Institute, and Joseph Bailes, MD, of the American Society of Clinical Oncology, began by framing the concept of value in cancer care as a ”twenty-first century” idea that has come to the forefront of oncology practice only in the past 5 to 10 years.
Lynn Zonakis of Delta Airlines described how the dramatically uneven distribution of health care costs has driven the discussion of value for major employers. Ms. Zonakis illustrated this point with data on Delta’s beneficiaries – of 200,000 beneficiaries with an active population of 82,000, 449 individuals are driving 77 percent of Delta’s health care costs. Of this subset, approximately 25 percent of the individuals have a cancer diagnosis.
Discussions surrounding the cost of cancer care and how cost should or should not be incorporated into the value equation led to debate. Lee Newcomer, MD, MHA, of UnitedHealthcare stated achieving value in cancer care occurs when outcomes or overall survival are improved at an affordable cost.
“What’s debatable,” said Dr. Newcomer, “is what people consider affordable.” He noted that “no one can demonstrate value” according to this definition, however, because the necessary data are not readily available.
A. Mark Fendrick, MD, of the University of Michigan, known as an expert in the area of value-based insurance design (VBID), noted that individuals have not been asking for information on cost and quality when purchasing health care. Dr. Fendrick also raised the issue of the economic stimulus package; provisions in the stimulus legislation about comparative effectiveness research had sparked contentious debate in Washington, as some stakeholders are pushing for cost to be “explicitly eliminated” from the value equation.
Dr. Bailes concurred with Dr. Fendrick’s view and stressed again the difficultly of assessing value in the absence of cost.
Bringing the focus back on the government, Scott Gottlieb, MD, of the American Enterprise Institute explained that increased government focus on cancer spending as a target for cost control has been driven by the growth trajectory of cancer care cost. He also discussed the political feasibility of cost control measures, comparing the relative ease of limiting access to technology rather than the difficulty of changing physician behavior.
Dr. Goodman sought a response on this issue from Robert Mass, MD, of Genentech, Inc. as to whether these discussions made industry uneasy. Dr. Mass responded that discussions on value were not uncomfortable for industry “because our goal is to create new products to help patients—that’s value in cancer care.”
Questioned about the cost and benefit of drugs and biologics manufactured by Genentech, Dr. Mass relayed that “our job is to provide the data to physicians so that they can make informed decisions. We set a price based on the value we perceive [the therapy] brings to the patient.”
Dr. Fendrick noted that leaving the decision up to the physician and patient creates a classic economic dilemma, as physician and patient are making decisions on how “someone else’s money” will be spent. Ms. Zonakis agreed with this assessment, adding that patients and their families would perhaps weigh treatment decisions differently if costs and benefits for various treatments were known and considered.
Dr. Gottlieb noted that “we’re really talking about price,” rather than discussing the possibility of a national entity that would define value. “This environment is the only one where a product’s usefulness increases over time and the price doesn’t change,” said Dr. Gottlieb, describing how prices for drugs and biologics do not increase over time even if new and proven benefits of these agents can be demonstrated.
Dr. Goodman then posed the question: “How much are we willing to spend for a year of life?” This question echoed discussions among the panelists regarding how other countries have addressed health care value.
Dr. Newcomer recognized that this would be a difficult decision to make, and not one that can be determined at anything less than a societal level. He cited the increasing pressure on society to control health care costs, describing how he currently learns of at least four $1 million cancer cases each week, a number that he would have been unheard of five years ago.
Dr. Newcomer also expressed that individuals are being forced into an increasingly worsening trade-off in purchasing health care coverage. He described rising costs of coverage over a 30-year span: in 1970, a minimum wage worker needed to spend 15% of his income to purchase a healthcare plan. In 2005, that same worker would need to spend 102% of his income for healthcare insurance. Dr. Newcomer predicted that the next economic collapse in the United States could originate in health care if the value issue is not addressed.
The audience asked several questions of the panel. One audience member petitioned for the development of guidelines to assist in end-of-life care; Dr. Edge noted that all of the NCCN Guidelines panels struggle with this issue because end-of-life care is highly individualized.
To conclude, Dr. Goodman asked the panel members how current economic conditions will affect the value the health care system places on a year of life. Although the answers varied, all panelists thought the value issue will continue to be at the forefront of debate.
Dr. Edge summed up the discussion by stating, “It’s going to force us to go back to basics.”