How to Create Value in Cancer Care

May 16, 2014
Craig R. Hildreth, MD
Craig R. Hildreth, MD

Take a minute to recall those patients who showed up in the emergency room without your knowledge, or who died 1 week after starting a new treatment, or whom you neglected to enroll in hospice. In each scenario the cost of their care rose without a corresponding increase in value. I’ve listed some behavioral skills that have a chance to prevent unnecessary expense.

Reporter: “Doctor, the cost of cancer care has increased to the point that our country’s financial future is in jeopardy. What is your solution to this impending crisis?”

Doctor: “That’s easy-stop treating cancer.”

In case you missed it, last month the federal government released copies of the $77.4 billion in invoices it paid to 880,644 health care providers in 2012. The official proclamation is published on the Centers for Medicare & Medicaid Services (CMS) website:

[CMS] has prepared a public data set, the Medicare Provider Utilization and Payment Data: Physician and Other Supplier Public Use File (Physician and Other Supplier PUF), with information on services and procedures provided to Medicare beneficiaries by physicians and other healthcare professionals.

This massive unloading, christened the “data dump,” has fired speculation about why some doctors were reimbursed millions of dollars more than others in the same specialty. Eyebrows have been raised and harrumphs have been registered, insinuating that shady behavior is the obvious answer, but at second glance it is easy to see that the raw data do not tell the whole story. For example, payments to oncologists are high mainly because of the high cost of the drugs and biologics we use, although those at the top of the list seem to have unloaded so many truckloads of the green stuff one wonders if their offices are open more than 24 hours a day. It certainly didn’t take long for the commentariat to pose the question: “Were these treatments necessary, or appropriate, or worth the cost? What was the value of these interventions?”

Spending $77.4 billion is certainly a quaint way to publicize the quest to find “value” in medical care. The American Society of Clinical Oncology (ASCO), in an “ASCO in Action Brief” on value-based care defines it as “the most effective treatment, given at the right time, for the appropriate patient.”[1] Corrective measures that have been already implemented in the name of increasing value include denying payment for tests and treatments that are not found in guidelines, using electronic medical records to track outcomes and compare providers, and limiting the use of expensive treatments that have not been shown to produce exceptional results (“exceptional” as defined by decree).

As a rather wary stakeholder in the behemoth of American healthcare, I tend to look at the value project a tad cynically. Whenever new suggestions appear after a long journey down Mount Sinai, my take is “Congratulations, but unless you can bend human behavior to your will you have little chance to rein in costs to any degree.” Gurus well-versed in the study of value-based care may be confident that recipes and regulations will produce results, but I believe that in order to really move the system forward you need to inspire oncology professionals to rethink their entire philosophy of practice. Stubborn minds with ingrained bias against value must be enlightened-preferably without resorting to Two-Minute Hates, posters of Big Brother, or telescreens in every room. By rebuilding and refining their skills from the inside out we can foster an army, an exaltation, a parliament, a shrewdness of assembled savvy professionals who know how to effortlessly provide high-value care.

Just take a minute to recall those patients who showed up in the emergency room without your knowledge, or those who died 1 week after starting a new treatment, or those whom you neglected to enroll in hospice care. In each scenario the cost of their care rose without a corresponding increase in value. I’ve listed some behavioral skills that have a chance to prevent unnecessary expense. Now it’s your turn, leave your ideas below.

References:

1. American Society of Clinical Oncology. ASCO in Action Brief: Value in Cancer Care. 2014 Jan 21.Read here.