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Focusing on Clinical and Economic Outcomes-Not Guidelines: Is It Time for a New Direction in Oncology Care?

Published: Wednesday, Apr 24, 2013
Andrew Pecora, MD

Andrew L. Pecora, MD

Editor-in-Chief
Oncology & Biotech News

Chief Innovations Officer, Professor, and Vice President
of Cancer Services

John Theurer Cancer Center
at Hackensack University
Medical Center

What’s your opinion today about the state of oncology care and payment?

Dr Pecora: Oncology is at a crossroads—more people are living longer, and therefore, more people will develop cancer, which means that we are using more drugs and surgical technologies to keep people alive longer. This means oncology care is getting more expensive, and on a macro level, this contributes significantly to increasing healthcare expenditures. Over time, some cancer care may become unaffordable, which could lead to the need to ration care—and that would be tragic. At this crossroads, we have to do something that allows us to modulate the growth of the cost of cancer care while avoiding rationing.

Healthcare payers are attuned to limited budgets and the possibility of rationing down the road. One way they seek to slow the growth in costs of oncology agents is by changing the distribution model, and moving toward the use of specialty pharmacy providers. Do you see that as a positive complement to provider side efforts to modulate the cost of cancer care?

I don’t know if that will avoid a discussion of rationing, but I really hope we can avoid that. I do believe that we need to do something different.

Efforts to improve compliance with clinical pathways are not all that helpful because that is a surrogate of quality and a surrogate of cost-effectiveness. On the contrary, I believe we should just go straight at it. We should insist on a certain progression-free survival and overall survival outcomes at a given cost, and let the providers decide how they’re going to accomplish that.

It sounds like trying to commoditize the quality outcome in cancer care.

This is a pathway away from having a nation of cooks and toward promoting a nation of chefs. If we set our sights on buying a specific outcome, then we can approach it like buying other products, such as a car or a computer tablet—you know what the output is, and you want the best possible cost to achieve it. That’s where we have to get to in cancer care.

Here’s a concrete example: If you know you can cure 80% of people using a 5-drug combination, but you can also cure 80% of people using a 2-drug therapy, we have to create the economic incentives to encourage prescribers toward that option. One might be to have the cost of the additional drugs come out of the pocket of the prescriber—that’s a bit simplistic, but it’s a critical point. This is different from saying, “We’ll pay you a bonus because you complied with this pathway.” We’re targeting the outcome, not the surrogate for quality care.

Therefore, we may instead say, “There are various ways you can achieve this outcome, but here is what we’re expecting to pay for this outcome. And, if you deliver it at this cost or even lower, there’s room for you to make a profit like any other business. The lower the cost for delivering this quality outcome, the more you make.” Now the incentive is completely aligned because you’ve pegged the outcome as the target. If the outcome is the target, there shouldn’t be a concern about lowering quality as you’re reducing cost.

So then the clinical pathway is basically irrelevant as long as it works?

That’s right. The clinician can use any pathway that works, but he or she must obtain the best outcome at (or below) the benchmarked cost.

Let’s use breast cancer as an example. A clinician may want to prescribe a patient Adriamycin and cyclophosphamide, but paclitaxel and cyclophosphamide cost the same amount of money, with identical outcomes. Should we spend time tracking prescribers on how they use one or the other (and did they give the doses on time), or do I just want to track the thing that counts the most—the patient’s outcome? If the outcomes are in line with what they should be, and the provider’s costs are not above what the cost should be, then that’s great. However, if the outcomes are poorer or the cost of treatment is greater than it should be, then my providers will hear from me.

Why shouldn’t we measure as the key outcome of what people are delivering—overall survival and progression-free survival—as long as it’s tied to an appropriate cost?

Let’s talk about Regional Cancer Care Associates (RCCA). How long has RCCA been in existence and what is your overall mission?

We came into existence January 1, 2012, and our mission is to provide the highest quality innovative cancer care, at the best possible cost.


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