Across the past year there's been more and more discussion about the cost of cancer care. ASCO has made it a top priority, even going so far as to provide guidance on how oncologists should discuss the cost of care with patients. New data released earlier this year in Health Affairs provide evidence that oncologists are increasingly accounting for the cost of cancer care, although they might not be proactively discussing costs with patients.
The survey is the largest to date to assess oncologists' attitudes about the cost of treatment and was conducted by researchers at both Tufts Medical Center and the University of Michigan. They found that 84% of oncologists consider patient's out-of-pocket costs when recommending cancer treatment, but less than half of surveyed physicians actually discuss costs with patients. Undoubtedly, as cost data becomes more readily available to physicians, this conversations will be easier to have. We actually looked extensively at how to help estimate costs up front to engage in these conversations - you can access that research here. Notably, the survey also asked about comparative effectiveness, and found that 79% of oncologists support more government research into comparative effectiveness.
A study released in last week's New England Journal of Medicine provides additional data supporting the potential role of shorter, hypofractionated radiation therapy treatment courses for breast cancer patients. The goal of the study was to determine whether a 3 week course of therapy was as effective as a 5 week course in women who had undergone breast conserving surgery, with clear resection margins and negative axillary nodes. They were assigned randomely to two groups: the control group received a standard dose of 50.0 Gy in 25 fractions over 35 days and the hypofractioned group received a dose of 42.5 Gy in 16 fractions over 22 days.
Results Indicate Hypofractionation Not Inferior To Standard Treatment
The women were followed for 10 years and the risk of recurrence was 6.7% in the control group compared to 6.2% in the hypofractionated group. In terms of cosmetic outcomes, 71.3% of women in the control group had a good or excellent cosmetic outcome compared to 69.8% in the hypofractionated group.
Time to Restructure Financial Incentives Accordingly?
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As part of our research on the Oncology State of the Union we reported on work United HealthGroup was doing to gather data on utilization of chemotherapy drugs by tumor type and stage. Their goal to assess whether physicians were delivering care in accordance with NCCN guidelines, and how this related to patient outcomes. As part of this work they also plan to send participating medical oncologists report cards detailing their performance. They've been collecting this data for past three years from 1,321 oncologists and early results are in, and they're interesting. For instance, their data indicate that for colorectal cancer patients, 31% of medical oncologists did not comply with guidelines which indicated patients should receive chemotherapy following surgery. Instead, the majority of those patients received Avastin as first line therapy when it is currently approved for metastatic or recurrent disease. There were similar findings in non-small cell lung cancer, as 24% of the patients received Avastin, even though they didn't fit the prescribing criteria.
The analysis also provided insight into patient compliance with oral drugs. Specifically, they found that 28% of breast cancer patients were not filling their prescriptions for aromatase inhibitors. There were numerous other metrics they looked at, each focused on ensuring patients are receiving the appropriate care.
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I spoke with my colleague Matt Garabrant the other day about the safety concerns around Radiation Therapy, and he wrote a nice blog post for me to share with you:
I wanted to revisit the topic I blogged about last week, in order to draw everyone's attention to some recent updates. The radiation therapy errors recently highlighted in the New York Times series initially spurred much discussion, but it's important to recognize that this discussion is also converting into action. ASTRO--the American Society for Radiation Oncology--has banded together with the ACR--the American College of Radiology--to publish formal practice guidelines for two of the newest types of radiation therapy treatments: Image Guided Radiation Therapy (IGRT) and Stereotactic Body Radiation Therapy (SBRT). While the errors highlighted in the NYT series focus on Intensity Modulated Radiation Therapy (IMRT) treatments, ASTRO already published formal guidelines on this modality in the August 1st issue of the Red Journal.
The goals of these most recent practice guidelines are to define the two treatment modalities, outline and explain the responsibilities of the healthcare professionals who are responsible for delivering them, and provide guidance around the quality assurance steps that are used to ensure their quality and safety. These new guidelines can be found here. While protocols exist, ASTRO is clearly making a renewed push to establish more rigorous guidelines around how RT is delivered.
As part of our research on what health reform means for oncology providers, we spent a lot of time focusing on the role of clinical pathways. One of the approaches we profiled was Innovent, a product launched by US Oncology (see our publication Developing the Care Delivery Model of the Future for more information). Early results of their work indicate that their pathways program can reduce costs of care without sacrificing outcomes - specifically, in a study of non-smell cell lung cancer (NSCLC), comparing "on pathway" and "off pathway" patient, "on pathway" patients saw a reduction of 35% in direct care costs (treatment and supportive care drugs, outpatient care, admissions etc) while maintaining equivalent outcomes.
In an era of accountable care, the focus in oncology will be treating the right patient, the right way, at the right time, and pathways will likely be at the core of this approach. With data like this indicating their value, adoption may start to happen sooner than we originally anticipated.
The economics of chemotherapy administration have always beent tricky, particularly for private practice medical oncologists. For a long time physicians wouldn't break even on the administration payment, but that was okay as profits on the drug were generous enough they more than subsidized the loss on administration. When Medicare transitioned to the average sales price (ASP) payment methodology, they were seeking to drive the outsized profits on drugs out of medical oncology (at least for Medicare patients), but in order to do this fairly they needed to boost administration payments. They did this initially, but now concerns have been raised that payments for chemotherapy administration have declined too much year over year, leaving them far under water. According to a study just completed on behalf of the Community Oncology Alliance, Medicare payments only cover 56% of the actual costs of administrating chemotherapy, raising concerns about whether private practice medical oncologists will continue to accept Medicare patients in the future, particularly given that payments for chemo admin are set to decline about 6% across the coming years. For the survey they spoke with 76 community oncology practices, representing 499 oncologists. Respondents reported annual bad debt of $500,178, driven in large part by an inability of patients to cover their co-payment (which for chemo drugs can be very large).
I have a few thoughts on these findings. First, yes they are concerning. It is imperative that Medicare adequately compensate physicians for the provision of cancer care. This means adjusting payments for chemotherapy so they adequately cover ALL the aspects of care (treatment planning, administration AND drugs). The fact that payments still do not cover the cost of administration is troubling.
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The American Society for Radiation Oncology (ASTRO) outlined an initiative on Wednesday to address concerns over patient safety, quality of care and the incidence of medical errors, the New York Times reports.
ASTRO, which the Times notes is the nation's leading radiation oncology group, is seeking several changes in the way radiation is administered and regulated, including:
- More robust accreditation and training programs;
- A national database to aggregate data on errors from linear accelerators and CT scanners;
- Federal legislation to codify national standards for radiation treatment;
- Supplementary resources for the Radiological Physics Center, which evaluates the safety of treatments; and
- Software interoperability between equipment manufacturers
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We've received a few questions lately regarding the likely downstream utilization of breast MRI from screening mammography. While there have beena number of helpful studies published recently regarding services downstream from mammography, these papers did not include breast MRI in the analysis.
One data comparison that may be helpful is to look at the number of outpatient breast MRI procedures versus the number of screening mammograms. Looking at 2008 estimated volumes, the number would come to 2.6 breast MRs for every 100 screening mammograms. That number is not precise, as it's not directly causal--there is a lot of breast MRI volume that is done for screening and therefore not directly downstream from a screening mammogram. But I think the numbers are helpful to consider.
At this point, perhaps the best thing to benchmark is breast MRI as a percent of total outpatient MRI volume. We estimate breast MRI now accounts for 2.6 percent of total outpatient MRI demand, with that growing to 3.0 percent by 2012. However, if your program is currently focusing on breast MRI growth, then your percentage may be higher.