Prepare for big changes ahead, Lawrence N. Shulman, MD, Senior Vice President for Medical Affairs at the Dana-Farber Cancer Institute, Brigham and Women’s Hospital, and Harvard Medical School in Boston, told oncologists at the 2013 Breast Cancer Symposium.1
One change is the emergence of accountable care organizations (ACOs). Since accountable care organizations are already abundant in the Boston area, Dr. Shulman has gotten a close-up look and he had some words of advice for clinicians: “You have to become attractive to accountable care organizations if you want to stay in business,” he said.
The Accountable Care Organization Model
Dr. Shulman has concerns about how oncology will fit into this paradigm, but the outcomes could be positive he indicated. “Partnerships are fruitful endeavors, but be sure the patient does not get stuck in the middle. Often, our choices are not patient-centered. We are all trying, but sometimes the system makes it very difficult. We need to keep the patient front and center,” he said.
The Patient Protection and Affordable Care Act of 2010 laid the groundwork for ACOs, and included the Boston area in its pilot programs. The model already includes Partners Healthcare (Massachusetts General and Brigham and Women’s Hospitals), Beth Israel Deaconess Medical Center, Lahey Healthcare, Steward (a private facility), and Atrius Healthcare (a large physician group). “ACOs are a big part of our world in Boston,” Dr. Shulman said, adding that “ACOs are permeating the medical world [in Boston], but the meaning for cancer care is still uncertain.”
The ACO population is no longer restricted to Medicare beneficiaries, but has widened its applicability to the general population. The ACO model is driven by primary care providers who will coordinate and direct care and, to some degree, be involved in treatment-related decisions. The goal is to provide quality care and reduce costs. The physician organization will supposedly benefit from costs that incur below the projected line and will be penalized for costs above that line. Physicians will be responsible for measuring and reporting quality metrics, Dr. Shulman said.
While the goals of ACOs are admirable, Dr. Shulman expressed concerns about how medical oncology will interface with primary care within this model. “Primary care providers may have something to say about the choice of a beta-blocker in a cardiac patient, but will they agree or disagree with the oncologist about the choice of an adjuvant chemotherapy regimen?” he said.
While they should, and probably will, leave such decisions to the oncologist, they will still maintain power over oncology practices, he suggested.
“Primary care providers may refer patients only to those oncologists who can measure and report quality metrics, as well as cost metrics. They may tell you that they will use your practice, or not use it, based on outcomes. Oncology practices will be most attractive to ACOs if they can measure and show competitive cost and good quality,” said Dr. Shulman.
Reducing Variations in Practice
Variations in practice patterns commonly occur among physicians and among institutions. This is sometimes related to the lack of good evidence as guidance, but it happens—and results in higher cost—even in the setting of evidence, Dr. Shulman said.
“As a nation we are not set up to be able to analyze the outcome of large groups of patients receiving routine care to better inform us of the best therapy for every clinical situation in the years to come,” he noted. “Maybe ASCO’s CancerLinQ™ [Learning Intelligence Network for Quality] will provide a better mechanism to analyze what we do in practice and to measure outcomes and cost.”
CancerLinQ™ will collect and analyze cancer care data from patient visits, creating a knowledge base that can be accessed in real-time by clinicians, researchers, and patients.
Meanwhile, physicians need to think beyond guidelines, which are focused on a particular decision point in care, and more toward pathways, which describe an entire course of treatment and specify “not only what should be done, but also what should not be done,” he said. Pathways must take into account the total cost of care and focus on practices that are truly needed.
Utilization and Cost Considerations
In the absence of phase III prospective randomized clinical trial data, said Dr. Shulman, oncologists should avoid “shooting from the hip” and should try to “reason out the best we can, in the theoretical.” And in the absence of data supporting a particular regimen for reasons of efficacy or toxicity, all things being equal physicians should choose the less expensive regimen or test, he advised.
“We must include issues of utilization and cost as we plan cancer care, and must do this prospectively rather than patient by patient,” said Dr. Shulman.
Case in Point
To illustrate how much oncologists can influence the cost of care, Dr. Shulman described the management options for a hormone receptor-positive, node-positive patient. Using average charges for 10 different management options, he showed that a course of adjuvant therapy could range from about $23,000 (with endocrine therapy and a short course of radiotherapy) to more than $130,000 (endocrine therapy, chemotherapy, radiotherapy, growth factor support, use of Oncotype DX).
“You can see that in this very gray area, choices impact cost a great deal,” said Dr. Shulman. “My own feeling is that much that we do day to day has only weak evidence to tell us the best treatment choices. The most interesting things we argue about in tumor boards are areas where the data are weakest. When options are relatively equivalent in efficacy and toxicity, we should take cost into account.” ■
Disclosure: Dr. Shulman reported no potential conflicts of interest.
1. Shulman LN: Accountable care organizations and the future in cancer care. 2013 Breast Cancer Symposium. Presented September 8, 2013.