Yousuf Zafar, MD, MHS
The estimated cost of cancer care in the United States was $125 billion in 2010 and is expected to rise to $175 billion by 2020.1 In an effort to reign in spiraling costs and deliver better care, the term “value” has become part of the new oncology lexicon, as providers, patients, and payers seek to find the best ways to deliver oncology services. The ASCO Post recently spoke with health policy expert Yousuf Zafar, MD, MHS, a medical oncologist at Duke University and a member of ASCO’s Government Relations Committee and Value of Cancer Care Task Force, as well as a past member of ASCO’s Health Equity Committee.
Please tell the readers a bit about your current work.
I am a medical oncologist specializing in gastrointestinal cancers. I’m also a health services researcher with a focus on improving care delivery for patients with advanced cancer. I’ve participated in multiple studies focusing on access to care, cost of care, and comparative effectiveness of care delivery between health systems. My current work is focused on reducing cancer patient financial burden through patient-facing interventions.
Value is a subjective term, particularly to a patient with a potentially deadly disease. How does the oncology community negotiate this delicate issue with patients?
It is true that in the clinical setting, value has different definitions depending on the stakeholder involved, and the best way to navigate that path is first by being cognizant of the various perspectives. For example, I think a value-based discussion at the societal level can be starkly different from one between a provider and patient.
The priority consideration of value for the patient is generally based on how to deliver the best possible treatment at the most affordable cost. On the societal level, the discussion of value still focuses on a treatment’s effectiveness, but there is also more of a cost-effectiveness component woven into the value equation. The larger societal questions that frame this discussion are: How much can we afford to pay for cancer treatment? And how much are we willing to pay for drugs?
When I have a cost discussion with a patient, it is really more about how I can help make that patient’s care affordable. Making that distinction is very important for patients. The anxiety that patients have about their oncologist bringing cost of care into the office setting stems from a fear that it will limit their options. But that is not what a discussion of cost is about. It is really about understanding how we as providers help our patients afford the best possible care. Financial toxicity is a real side effect of cancer treatment, so cost and value are crucial to the patient’s outcomes.
Are there any models or tools that can help busy community oncologists in these discussions?
I’m not aware of any perfectly designed tools that oncologists can use to help relate cost considerations to their patients. But I don’t think we need to get fancy about it. In a busy practice, a clinician needs to ask whether the patient can afford the care that they’ve discussed. If the answer is no, the oncologist can refer the patient to a financial counselor or a pharmacist associated with the practice who can assist the patient with financial aid. Oncologists should think of themselves as the first line of defense when it comes to identifying their patients’ financial circumstances and potential challenges.
Reining in Costs
How can we rein in the rising costs of cancer care and still provide our patients with quality care?
The fee-for-service payment model is a problem for the health-care system at large. But if you look at the early results from the Center for Medicare and Medicaid Innovation Oncology Care Model, they suggest that even when you introduce value-based models, the costs do not decrease all that much in the short term.
A lot of that has to do with the cost of drugs. So while we need to think about new, more creative ways to deliver care and reduce waste and redundancy, we also have to figure out ways to reduce the rising costs of the drugs we prescribe.
“Financial toxicity is a real side effect of cancer treatment, so cost and value are crucial to the patient’s outcomes.”— Yousuf Zafar, MD, MHS
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One strategy used in several other countries is negotiating drug prices, but our laws proscribe that. In Europe, for instance, the cost of a drug is factored into the approval process, but here we have powerful special interest groups that lobby against that kind of model.
Role of Prevention
In the discussion of value-based care, why aren’t we spending more of our energy on cancer prevention?
Part of the answer is based on the way our insurance system is structured in that many strategies on the prevention front are not sufficiently covered. That said, we need to do more as a community in effecting behavioral and lifestyle changes, especially when it comes to obesity.
I did work in Tanzania, helping to set up a cancer registry, and there is evidence that as low- and middle-income countries become more Westernized in behaviors such as lack of exercise and diet, we see obesity and cancers that we’d never seen before in these populations. So we’ve identified obesity as a huge problem associated with the development of multiple cancers; now we need to implement population-based strategies to combat it.
Do you have any parting thoughts on value in cancer care?
Perspective is so important around value and cost of care in doctor-patient communication. There are so many stakeholders in this issue, and intervention truly needs to occur simultaneously at both the policy level and the provider-patient level. Deriving optimal value from cancer care is a complicated issue, but we need to drill down to the core elements.
And part of value-based care is the provision of equitable care among all of our patients. Despite great improvements in cancer screening and treatment over the past several decades, segments of our population still experience substantial inequities in access to care, quality of care, and cancer outcomes. ■
DISCLOSURE: Dr. Zafar is a consultant or advisor for Family Reach Foundation, AIM Specialty Health, and Vivor. His institution has received research funding from AstraZeneca, and an immediate family member is an employee of and owner of stock in Novartis.
1. Yu PP: Challenges in measuring cost and value in oncology: Making it personal. Value Health 19:520-524, 2016.