2012 EDUCATIONAL BOOK - American Society of Clinical Oncology

non–evidence-based cancer care have also been documented.
18 However, it is likely that in some settings we will
face real trade-offs between marginal benefits of an intervention
and additional cost. For example, one year of trastuzumab
for HER2-positive breast cancer reduces the risk of
recurrence by close to 50% compared with chemotherapy
alone, but at an additional cost of approximately $50,000 per
patient. 19 Recent data in both the neoadjuvant and metastatic
breast cancer settings suggest that additional interventions
above and beyond trastuzumab, such as lapatinib
and pertuzumab, may further improve outcomes for some
patients. 20,21 If additional benefit is confirmed in large
adjuvant randomized trials, one can imagine a scenario in
which we are forced to decide on further improving outcomes
versus doubling or tripling the cost of therapy. In fact,
throughout oncology, novel interventions are improving outcomes,
but in many cases such progress comes at a substantial
price. 13,22
If, as is currently the case, interventions continue to be
approved on the basis of marginal benefits in efficacy, how
will oncologists decide which interventions truly bring
meaningful clinical benefit? What role will patient preference
or shared decision making have in an era of increased
pressure to control costs? If nothing else, the recent decision
by the U.S. Food and Drug Administration (FDA) to withdraw
approval for bevacizumab in breast cancer demonstrated
lack of consensus on what constitutes value in
oncology among both clinicians and patients.
Many of these tensions exist within the current health
care system. They may be magnified if there is an assumption
of universal access to cancer care that is not matched
by the actual reimbursement for services. Will patients with
different forms of insurance within the new system be
treated differently? Will treatment decisions vary for patients
who are within or outside of an ACO?
In the setting of expanded access and pressure to control
costs, oncologists may face ethical challenges related both to
how they practice and whom they are willing to treat. With
more insured patients there may be greater demand for
oncology services, but as noted above, it is expected that
important differences in the adequacy of coverage for cancer
care will persist. Will the expanded cohort of patients with
Medicaid and continued low reimbursement levels paradoxically
push a greater number of oncologists to close their
practices to Medicaid? Where low reimbursement for a small
percentage of patients might be subsidized within a large
practice, the potential economic impact of a larger share of
such patients might prove to be too great a risk in some
settings.
In addition, the ACO model of rewarding physicians and
practices for improving the quality, coordination, and cost of
care may create a disincentive to treat more complex patients
who may require care outside of the expected norms.
On the basis of unusual disease presentation, tolerance of
standard therapies, or comorbidities, some patients may
require oncologists to either step outside of the standard
care plans and consider options that might be more expensive
than the norm. As noted herein, this will even be
facilitated under the new law through a strengthened right
to appeal coverage decisions. There would seem to be a clear
incentive to both provide treatment for patients with less
complex disease, whose expected costs of care are likely to
e6
be at or below the average, and to constrain our decision
making for individual patients.
There are clearly some pitfalls ahead, primarily in the
area of cost containment, and no easy solutions. The question
will be how to find the balance in our practices between
advocacy for our patient’s interests and preferences and
some effort to consider wise and efficient use of resources.
Failure to strike this balance may leave us with a “tragedy
of the commons” in which individual decisions to ignore
societal costs of care results in unsustainability of the entire
system, and threatens our ability to guarantee high-quality
cancer care to all patients.
The ACA and Oncology Stakeholders
As demonstrated in the preceding section, the ACA promises
to change the landscape of health care for virtually
every stakeholder. Insurance reforms will inevitably lead
to changes that will dramatically affect the composition of
populations of patients with cancer around the country. A
focus on health service delivery innovation, comparative
effectiveness research (CER), and reducing health care disparities
will shift the profile of cancer research.
Oncology Workforce
MOY, ABERNETHY, AND PEPPERCORN
In addition to the ethical considerations and the projected
increased demand for oncology care outlined above, improvements
in access to health care will affect the oncology
workforce. Support for new models of health care delivery
under the ACA will help meet escalating demand for cancer
care. The ACA established the Center for Medicare &
Medicaid Innovation (CMI) to test innovative payment and
service delivery models to reduce Medicare and Medicaid
expenditures while improving quality of care. Beginning
with its Health Care Innovation Challenge program in 2012,
CMI will provide funding to demonstrate rapidly deployable
new models for reducing total costs of care while improving
quality and health outcomes; proposed models will likely
address access and volume in the context of resource constraints.
ACA encourages models, such as the medical home and
ACO, which are designed to optimize care and largely focus
on community-based delivery through which the majority
of patients access cancer care. A common theme among
the various emerging delivery models is coordination of
care. Models for which ACA authorizes funding include
(1) community-based collaborative care networks—consortia
of health care providers that include a safety-net hospital,
have a joint governance structure, and provide comprehensive
coordinated and integrated services to low-income
populations; (2) interdisciplinary, interprofessional teams of
health care providers who work with primary care providers
to provide integrated community-based care; and (3) community
health centers, which serve an estimated one in
three low-income people and one in four low-income minority
individuals. Provisions pertaining to medical homes
allow states, under Medicaid, to make medical assistance
payments at an enhanced federal match to teams of providers.
Clearly, under the ACA, coordinated care and clinician
teamwork will increasingly become the norm.
Provider organizations are encouraged, through the ACA,
to expand and diversify their workforce. Through the Centers
for Disease Control and Prevention (CDC), the law