Value-driven cancer care

Healthcare reform is about much more than extending coverage to the uninsured, but that’s arguably its key feature. The addition of 40 million people who currently don’t have insurance will force big changes to the healthcare market. For good or ill, economic forces set in motion by this and other provisions of the Affordable Care Act will radically alter how we all receive care. Its promise is that new business models will tame the relentless medical inflation that threatens to render healthcare unaffordable for nearly everyone, if it doesn't first bankrupt the nation.

It’s my fervent hope that changes in the oncology marketplace will lead to better care and lower costs. If we can satisfy those two requirements while allowing providers to make a profit, then I’m all for it. Without sufficient economic incentive, we will fail long-term in bringing oncology costs under control. The cancer care market is growing by more than 5% per year and cancer-related spending is on track to exceed $100 billion in the next five years. This is partly due to the aging of the population, which increases the number of people diagnosed with cancer. Cancer will soon surpass heart disease as the leading cause of death in the U.S. But growth of the cancer market is also related to the availability of new treatments that let many patients live—and receive treatments—longer, thereby increasing both the prevalence and the cost of the disease.

Case in point: Some very expensive drugs have emerged this year for treating patients with advanced melanoma that guarantee that the costs of patient care will continue to increase. Both of these new treatments can (in some patients) extend life but they do not cure. As new drug therapies are developed for relatively small numbers of cancer patients, costs will spiral even higher—assuming the FDA approves and Medicare covers them. These drugs will only reach the public if the companies that make them know they can be profitable, and to be profitable, they will be exorbitantly priced. It’s estimated that while oncology patients under active treatment represent only 1% of a payer’s patients, their care accounts for about 10% of their costs. Uncoordinated cancer care in which every patient runs the gauntlet of treatment options could literally be the straw that breaks the back of the U.S. economy.

It’s the addition of those 40 million new healthcare customers that may save us. A government-sponsored retail insurance market will peg its reimbursement rates well below standard employer-sponsored plans. To compete for this business, providers will need to develop a deep understanding of the clinical economics of complex cancer care and then build systems that deliver both excellence and value. The fee-for-service model, in which the more you do the more you make, must end. Payment models and profit dynamics that are tied to performance and outcomes are needed to create a system in which costs increase no faster than the rate of overall inflation.

In my five-year journey through cancerland, there’s been very little coordination among my care providers. I’ve had to navigate the system on my own, and stage and sequence my treatments with the advice of unrelated medical professionals. I’ve managed OK, but this sort of fragmented care drives up costs in that no one is incentivized to contain costs, much less to optimize the quality of my care. I’m fortunate in a couple of regards: my surgeon and my oncologist, who belong to different systems, at least communicate regularly in case reviews; and my surgeon is willing to perform many of the procedures I’ve required in his office, and not in the hospital OR (where costs are about 10 times higher).

I trust my surgeon, but the OHSU cancer center, where he is on staff, is not even ranked in the top 50 cancer centers in the U.S. I partly attribute this mediocrity to the conspicuous absence of patient care coordination. There is no one at OHSU looking out for me—meaning I receive episodic care as circumstances demand it. Based on what I read and hear from other patients, this approach is more the rule than the exception. It’s what most cancer patients, frustrated as they may be, have come to expect.

This system, for all its achievements, is simply not aligned to deliver consistently excellent cancer care at an affordable cost. Most healthcare organizations know how they can improve, but lack the will to drive the required changes. So long as the system financially rewards each doctor, hospital, therapist, independent diagnostics company, freestanding lab, etc., separately, there is no incentive to change. This is why, for all its faults, I support the Affordable Care Act—otherwise known as Obamacare. Competition for 40 million new customers may be just the fillip the system needs to usher in more value-driven care.