Washington, DC—“While our country has been fixated on the fiscal cliff, the profession of oncology has been facing, quietly, its own survival cliff,” said Barry V. Fortner, PhD, Senior Vice President of Payer Strategy and Sales at ION Solutions in Frisco, Texas, at the Association of Community Cancer Centers’ annual meeting.
Yet, according to Dr Fortner, regardless of the politically charged atmosphere in which all of healthcare currently finds itself, there is a legislated march toward a concept of value, with physician payments based not on production but on services rendered to the patient. Community oncology now finds itself needing to evolve with the new concepts of accountable care organizations, health insurance exchanges, clinical pathways, and medical home models.
In particular, Dr Fortner explained, community oncology—defined as privately owned, local community practices—faces new levels of stress that have never been seen before, which has been caused by the continued downward spiral of drug reimbursement and encroachments on oncology practices’ ability to buy, bill, and dispense the drugs they need for their patients’ treatments.
“While I’m sure The New York Times can find one,” Dr Fortner quipped, “I’ve never met an oncologist who was not pro-quality. I’ve never met an oncology nurse who was not pro-patient centeredness. I’ve never met an oncology practice administrator who was not pro-cost effectiveness,” he said. “The issue is not whether we pursue these things. The issue is how do we pursue them so that while we reach for new levels of value, we don’t destroy the value we currently have?”
The First 3 Elements of Value
According to Dr Fortner, the first 3 qualities that define value for patients with cancer are proximity to care, availability of care, and access to care, and these qualities matter especially in vulnerable populations, such as rural and low-income patients. This is where he says the private community oncology practice can create value for these patients. “Having a local practitioner matters to the widowed patient, to the low socioeconomic patient,” Dr Fortner explained. “That 5, 10, or 15 miles of drive time has implications—real, practical implications in patients’ lives that translate into delaying care, experiencing less intensive care, or, ultimately, receiving less care than they actually require.”
He cited a study on chemotherapy recession within 3 months of resection in patients with colon cancer that was published in the Journal of Oncology Practice which found that when compared with service areas where there was no medical oncologist, patients were 1.451 times more likely to receive chemotherapy in that 3-month window if there were 1 to 3 medical oncologists available, 1.5 times more likely to receive chemotherapy if there were 4 to 8 medical oncologists available, and 1.3 times more likely to receive chemotherapy if there were more than 9 medical oncologists available in their geographic area.
“Proximity matters. Availability of care matters. We simply can’t talk about value if we’re going to restrict access to care,” Dr Fortner said. “If we’re going to create a value story, we have to talk about access to care, which is predicated on a fundamental dynamic in which there is an array of sites of care, in which there is a foundation of community practices that represent frontline care, and where care can be triaged to other areas depending on the clinical needs—and even the location—of the patient.”
The Last Element of Value
The last critical part of the value equation, of course, is cost. Dr Fortner told the audience there is no denying that the cost of cancer care over the past several decades has increased exponentially, to the point that it has now reached a threshold that has made society start paying attention.
He explained that before 1990, oncologists only had “3 double fistfuls of drugs” with which to treat their patients, and it was the therapeutic discoveries of the 1970s and 1980s that led to the explosion of clinical trials and US Food and Drug Administration (FDA) approvals that began in the late 1980s and continued into the 1990s.
“That resulted in what I would say is nothing short of an evolutionary burst in oncology,” Dr Fortner said. “It’s no wonder that cost increased as we began to see scientifically validated, FDA-approved treatments for most lines of therapy within the major disease categories. This in turn created a supportive care portfolio that let us take cancer care from an inpatient setting, to a contiguous outpatient setting, and, finally, to a detached, community-based infusion center model—the birth of a delivery system known today as community oncology.”
Now, Dr Fortner noted, the argument on value is a bit more subtle. All of the drugs that came to market in the 1990s are coming to maturity in the next decade. Whereas the rest of the pharmaceutical industry has already faced its generic cliff, oncology is just now reaching the precipice of its own generic cliff. By 2022, virtually the entire drug portfolio that oncologists rely on today as the mainstays of their chemotherapy armamentarium will turn over to generic chemotherapeutic drugs, which will fundamentally change the way a drug is tested, approved, and brought to market.
There will be new drugs, Dr Fortner says, and they will be expensive. However, there will also be an existing foundation of cancer drugs that cost substantially less than the new, innovative drugs that will just be coming to market. In fact, he told the audience, it is happening already, because when a cancer drug “goes generic,” the price of that drug plummets.
“In fact,” Dr Fortner noted, “there is actually a positive incentive under ‘buy and bill’—at least during the period in which the price of the drug is declining—for physicians to use the generic drug. We all look for new ways to create incentives for the use of generics but we already have a way—with no external pressure, no external control. Again, we’re looking for value dynamics, as this is one of them.”
Although the new cancer drugs that are either currently or will be in research and development may be tremendously expensive when they finally hit the market over the next decade and beyond, Dr Fortner reminded the audience that it behooves all of oncology that the pharmaceutical industry keeps innovating, saying that the future of pharmacogenomics has huge potential to be disruptively innovative. “That’s value, and with the maturity of our drug portfolio, with the development of targeted therapy, with accessible care, where evolutionary pressures have forced efficiency amongst our predominant delivery system, we are poised to produce even greater levels of value,” he said.
Yet, he continued, the untold value story is that the predominant cancer care delivery system in the United States is, actually, a good deal. According to IMS Health, the overall spending on cancer pharmaceuticals through 2016 is projected to be 3.8%; however, by putting the value of 1 year of life at a conservative European level of $150,000 a year, the US cancer care system delivered more than $600 billion in value above what was delivered by the European system. In other words, Dr Fortner explained, from 1995 to 2000, for every additional $20,000 that US oncologists spent on a patient with cancer than their European counterparts, the US patient’s life expectancy increased by 2.3 years.
“The fact is that the data and the arguments are on our side. If we cooperate and we tell the story, and if our patients understand it, if the payers understand it, if the government understands it, if society at large understands it, then someday we may look back on this cliff we’re facing right now and see it as a triumphant summit,” Dr Fortner finished.