Efficiency in Cancer Costs Can be Achieved Without Sacrificing Quality, HICOR Report Finds

Gary H. Lyman, MD

Gary H. Lyman, MD

The Hutchinson Institute for Cancer Outcomes Research (HICOR) released the first Community Care Cancer in Washington State: Quality and Cost Report to provide transparency for patients and health providers, establishing a more value-based care model.¹

As the cost for cancer care continues to rise, the quality of care does not necessarily follow the same path. Many users blame the United States’ fee-for-service healthcare model, where health providers are incentivized to provide more services regardless of any added value. Although government policies have initiated a move to a more value-based healthcare system, such as the Oncology Care Model, little has been done to define what is considered value-based care and what is not.

This sparked the interest of HICOR, a multidisciplinary team of public health researchers who seeks to provide patients with high-value cancer care.

“I felt it was imperative that we engage everyone involved, including patients, providers, health systems, and payers, to come up with reasonable approaches to improve the quality of patient care while constraining costs and improving the overall value of what we provide to patients,” Gary H. Lyman, MD, professor of medical oncology, University of Washington School of Medicine, and co-director of HICOR, said in a statement.

The report provides a highly transparent “snapshot” of cancer clinic performance by comparing hospitals and clinics to their combined average on selected variables regarding quality and associated cost within the state of Washington.

The quality and cost variables include: recommended treatment for breast, colorectal, and lung cancer; hospitalizations during chemotherapy; follow-up testing after breast, colorectal, and lung cancer treatment; and end-of-life care.

A patient-level database was constructed by HICOR from Washington state cancer registries, which provide health utilization and cost data. This included an estimated 70% of patients with cancer who received care in Washington between 2014 and 2016 (the reporting years) and were covered by the state’s largest public and commercial insurance providers.

From more than 25 different Washington state clinics, the data was measured for quality following National Comprehensive Cancer Network guidelines and public reporting from the Centers for Medicare and Medicaid’s Measure Management System, the National Quality Forum’s Measure Developer Guidebook, and performance measurement literature.

The study found that 85.6% (range, 83.5%-87.4%) of patients received the recommended therapy for their cancer type. Additionally, 97.7% (range, 93.5%-98.5%) of patients received the recommended anti-nausea medication during chemotherapy treatments.

The regional average for cancer care cost over the reporting years was $71,647 (range, $62,292-$83,935); however, there was no relationship found between the quality variable of recommended therapy and associated cost. HICOR notes in the report that this finding could suggest the possibility of lowering costs without sacrificing quality.

While most patients were shown to have received the recommended treatment, 52% of patients with cancer had either an emergency department (ED) visit or an inpatient hospital stay within 6 months following the start of their chemotherapy.

Additionally, a strong negative relationship was noted between episode cost of hospitalization during chemotherapy and quality of care, suggesting that an improvement in quality could ultimately lower cancer care costs. The regional average is $51,561 (range, $42,758-$61,848) for hospitalization during chemotherapy, with a significant difference of 22.6% between the highest-performing clinic and lowest-performing clinic.

For those who received end-of-life care during the reporting years, 5.8% of patients (range, 3.0%-9.0%) received chemotherapy in the last 14 days of their life and 12.6% (range, 9.7%-19.0%) had more than 1 ED visit in the last 30 days of their life.

While 20.2% of patients (range, 10.8%-37.1%) were found to have stayed in the intensive care unit (ICU) in the last 30 days of their life, 62.5% (range, 43.7%-80.9%) enrolled in hospice care 3 or more days prior to death. Both findings had wide ranges, suggesting a considerable difference in end-of-life management between clinics.

Authors stated that clinics, on average, who received higher scores for hospice care tended to have lower rates of chemotherapy administration, ED visits, and ICU stays. End-of-life care was also noted to have the greatest variation in quality measurement among clinics within the study.

The study found a strong negative relationship between episode cost and quality score, indicating higher quality is associated with lower costs for end-of-life care. While ICU stays are associated with higher costs, hospice care is associated with the lowest costs.

Several limitations were noted in the report, including the exclusion of out-of-pocket expenses, patient preference for treatment and end-of-life care, and patient-level factors that influence outcomes but are outside of the clinics’ control.

On a broader level, HICOR has also performed studies comparing the quality and cost of cancer care in the United States versus other countries.

A study presented by HICOR at the 2018 ASCO Annual Meeting found that the average costs across all chemotherapy treatments for a patient with metastatic colorectal cancer were $12,345 each month in Western Washington versus $6,195 each month in British Columbia.²The study also noted that there was no difference in overall survival between the 2 locations.

The study also showed that chemotherapy was more likely to be administered to patients in the United States (79%) than to those in Canada (68%).

With infamously high prices for cancer care rampant in the United States, HICOR encourages clinics to utilize the Community Cancer Care Report to better enhance their health services. For example, treatment centers that have a higher quality of care should share best practices with those looking for ways to improve.

“As the medical oncology community, we do have the obligation to bring the work to improve the quality of care while bringing the cost to a manageable level. HICOR took a major leap toward bring all sorts of organizations from community, large hospital systems to academia to work together to achieve this goal in [Washington],” said Sibel Blau, MD, medical director of hematology-oncology, Northwest Medical Specialties, and a member of HICOR, in a statement.

References:

1. Community cancer care in Washington state quality and cost report 2018. Fred Hutch website. https://www.fredhutch.org/content/dam/public/labs-projects/hicor/CCCReport/HICOR%20Community%20Cancer%20Care%20Report%20May%202018.pdf. Published 2018. Accessed June 4, 2018.
2. Yezefski T, Le D, Chen L, et al. Comparison of chemotherapy use, cost, and survival in patients with metastatic colorectal cancer in Western Washington and British Columbia.J Clin Oncol. 2018;36(suppl; abstr LBA3579).