Managing Cancer Outcomes and Cost—A Balancing Act

It is growing more difficult to manage cancer care. A solid foundation of care incorporates evidence-based medicine with personalized care and network strategies—and helps improve quality outcomes while reducing cost. Achieving this model of care is a challenge for providers and payers in the evolving cancer landscape.

“Cancer is not a single disease and it is naïve to think that there is a common pathway that we can identify and modulate for everybody that has ever had cancer,” said Arthur H. Rossof, MD, FACP, oncology medical director, Optum. Dr Rossof shared his remarks during Optum’s webinar “How Oncology Is Changing and What It Means to Health Plans” hosted by America’s Health Insurance Plans. Optum, part of UnitedHealth Group, is an information and technology-enabled health services business.

Historically, the primary treatment options for cancer included surgery, radiation, and chemotherapy. “We used to think that the more treatments we could throw at patients the better it would be for them in the long run,” he recalled. “In many cases, we brought patients to the verge of mortality. We are beginning to learn that the ‘more is better’ concept is not necessarily true any longer.”

Now, the treatment paradigm is changing with targeted therapies based on better diagnostics. Therapies include surgery, radiation, chemotherapy along with new adjuvant therapies, combination therapy, immunotherapy, and biologics.

Managing and treating cancer imposes a significant burden on health care, particularly with cancer rates rising. The American Cancer Society projected 1.7 million new cancers diagnosed in the United States in 2015, according to Dr Rossof. One factor contributing to this increase is that cancer tends to be a disease of an aging population that is living longer (60% of cancer diagnosed is among individuals older than 65). Cancer is the second most common cause of death in the United States, exceeded only by heart disease. Dr Rossof said the good news is that the 5-year relative survival rates are increasing because of prevention, early diagnosis, and improved treatments. He said projections show that by 2024 approximately 19 million Americans will be considered cancer survivors.

The flip side to improvements in diagnostics and treatments for increasing cancer survivors is cost. Cancer survivors cost 2 times more than those without cancer as a result of frequent physician visits and more expensive tests to screen for a return of cancer, a new cancer, or, in some cases, the consequences of prior successful cancer therapy, said Dr Rossof, noting that the National Cancer Institute projects the US annual cancer cost at $207 billion by 2020.

Pharmaceutical companies are also developing new costly therapies. The cancer drug pipeline has approximately 1000 new drugs in development at any given time. These therapies can cost approximately $10,000 a month, with full course of therapy costing about $100,000 a year, he said. New technology adds to the economic toll. For example, proton beam therapy is “being touted as a substitute for conventional radiation therapy,” he said, however, this technology requires different equipment than the conventional radiation therapy and costs up to $200 million to build a proton facility. Additionally, this advanced technology has not been proven to provide better outcomes over intensity-modulated radiation therapy or conventional radiation.

Reimbursement for cancer treatment is an important factor impacting the cancer cost for providers and payers. On the provider side, clinicians are pressured to see more patients and reduce patient visits to 10 to 20 minutes. Also, oncologists are paid on a fee-for-service scale. As reimbursements from Medicare decreased, oncology practices were bought by hospitals and the costs to payers increased.

The pressure on the marketplace, the payers, providers, and patients is becoming increasingly complex, according to Melissa Lindholm, MBA, senior director oncology, Optum. “We expect cancer to be the number 1 medical expense within the next couple of years due to what we think of as the ‘perfect storm.’ The marketplace has changed, the population has aged, and new technology and treatment are all combining to increase the cost for the overall payer.”

She discussed best-practice approaches for controlling costs, while meeting the care needs of cancer patients. “Providers want the best outcomes for their patients, patients want to survive, and payers want to make sure they have a sustainable business model in place,” said Lindholm.

Solutions that align the needs of the key stakeholders—payers, providers, and patients—are needed to manage both the quality of cancer care with the economic burden. She said the industry has seen a shift among providers focusing on evidence-based treatment guidelines and pathway guidelines when determining a course of treatment. The industry is also seeing the proactive prevention of side effects by using oncology clinicians to help support patients and an increase in services that provide the right supportive care at end of life.—Eileen Koutnik-Fotopoulos