The Quality-Cost Connection in Cancer Care: Lessons from Oncology Practices in Washington State

February 2019, Vol 9, No 2

Although many quality measures exist in oncology, few efforts have been undertaken to prioritize, measure, and report quality and costs for an entire region. A recent multiyear, multistakeholder effort to characterize quality of care and costs for Washington State oncology practices revealed that increased quality may be associated with a reduced cost of care in oncology.

At the 2018 ASCO Quality Care Symposium, Scott Ramsey, MD, PhD, Director, Hutchinson Institute for Cancer Outcomes Research, Fred Hutchinson Cancer Research Center, Seattle, WA, presented the findings from the first-ever Community Cancer Care in Washington State: Quality and Cost Report 2018.1

According to Dr Ramsey, the report was aimed at improving care and lowering costs by spurring collaboration, research, and innovation among oncology practices and other healthcare stakeholders. Based on input from and cooperation with multiple stakeholders, he and his colleagues set out to create a transparent process to prioritize, create, and publicly report a core set of quality and cost metrics for all oncology practices in the state of Washington.

“It’s important to emphasize how much time and effort we took to make sure that this was a transparent process that had input from our stakeholders every step of the way,” Dr Ramsey said.

Building the Metrics

They selected quality metrics from nationally recognized measures through a structured process involving 28 oncology provider clinics and the Washington State Medical Oncology Society, health insurance leaders, patient advocates (including minority advocates and 20 individual patient representatives), and policy and research experts.

During the entire research process, a steering committee and a data methods committee—comprised of representatives from the clinics, insurers, and patients—assisted in completing and building the metrics.

“Each year, we rolled out portions of this; we started with the Regional Metrics Quality Report in 2015, and we added cost in 2016. In 2017 we highlighted and identified publicly, for the first time, the highest-performing clinics across each quality metric,” he explained. “And then in May of this year, we released the Community Cancer Care Report for all clinics for quality and cost.”1

To build the report, they linked state cancer registry records between 2014 and 2016 with claims data from 2 commercial insurers and Medicare. This provided clinical information, utilization, cost, and survival data for approximately 70% of patients with cancer in Washington.

Patients were assigned to oncology clinics using claims data, and 27 clinics were large enough for inclusion in at least 1 measure in the report. The stakeholder groups agreed on 13 metrics that were then combined to produce 1 clinic-level quality score for each of 6 measures:

  • Recommended treatment (breast, lung, and colorectal cancer)
  • Recommended treatment (breast cancer only)
  • Advanced imaging after treatment (breast, lung, and colon cancer)
  • Hospitalizations during chemotherapy
  • Advanced imaging and tumor markers after treatment (breast cancer only)
  • End-of-life care.

Each quality score was mapped to total episode-based cost per patient, and results were adjusted for clinic size, cancer characteristics, demographics, and comorbidities, where appropriate.

Negative Relationship Between Cost and Quality

Dr Ramsey presented the data for hospital and emergency department admissions during the first 6 months from the start of chemotherapy.

Overall, 29% of patients had at least 1 emergency department visit, and a 13% difference was found between the highest- and lowest-performing clinics. A total of 37% of patients had at least 1 hospital stay, resulting in another 13% difference between the highest- and lowest-performing clinics.

“Overall, I think it’s important to note that 52% of patients in our state who started chemotherapy ended up in the ED [emergency department] or hospital during that 6-month period,” he noted. “And in the lowest-performing clinic, 80% of patients had at least 1 ED or hospital visit.”

For the measure of emergency department visit, a strong negative relationship was found between the quality score and the cost of episode of care, suggesting that efforts to lower the number of emergency department visits would amount to improving care quality and could also lower the costs of care, Dr ­Ramsey observed.

Strong Connection of Cost and Quality: The 3 Key Measures

The researchers found that some measures did not show any relationship between cost and quality of care, such as recommended treatment for breast, lung, or colorectal cancer. The quality scores for these measures remained high, with little variability between clinics.

However, 3 measures showed a strong relationship between quality and cost of care:

  • Hospitalization during chemotherapy
  • Advanced imaging and tumor markers after treatment
  • End-of-life care.

These 3 measures had, by far, the most variability, amounting to almost a 60-point difference between the highest- and lowest-performing clinics. And in all cases, the clinics delivering the higher quality of care also had lower costs of care.

Protecting Practices

“Even though we were very transparent, and we involved the clinics during this 5-year journey at every step of the way, you can imagine that some [people] would be a bit anxious about having this reported publicly for all to see,” Dr Ramsey said. “Our purpose was certainly not to name and shame,” he emphasized.

To ensure that goal, the research team established rules of use for all stakeholders. The rules state that for at least 2 years after the release of the report, the data may not be used to establish insurance coverage networks, design employee benefit packages, negotiate contracts without mutual agreement from all involved parties, or for advertising or marketing purposes by clinics and payers.


  1. Fred HUTCH. Hutchinson Cancer Research Center. Community Cancer Care in Washington State: Quality and Cost Report 2018. Seattle, WA. May 1, 2018. Accessed December 17, 2018.

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