Developing a Framework to Assess Value in Cancer Care

Richard SchilskyRecently, there has been a shift among payers, providers, and patients towards a focus on demonstrating proven, quantifiable value in health care. This shift has sent ripples through the entire oncology care setting, driven by the greater availability of higher quality data as well as the rapidly increasing costs of cancer care.  

Numerous experts within the industry have noted such a shift. Caleb Stowell, MD, and Christina Akerman, MD, members of the International Consortium for Health Outcomes Measurement, wrote recently in the Harvard Business Review1 about the necessity of building value-based strategies for care on the basis of strong and consistent outcomes data. In fact, incorporating data into decision-making is no longer just a recommendation but could determine a practice’s success or failure.1 In a joint survey conducted by the Association of Community Cancer Centers (ACCC) and Lilly Oncology, an overwhelming 92% of the cancer programs surveyed reported using some kind of metric to measure their outcomes.

Providers have since initiated a number of different efforts to bring patients into this discussion and help them to assess high-value cancer care. A team led by Peter Bach, MD, at Memorial Sloan Kettering Cancer Center developed Drug Abacus (www.drugabacus.org), an online tool that gives patients access to detailed information on the different drugs available to them. Patients using the tool are able to select the factors most important to them, whether it be price, toxicity, novelty, or the cost of development. The tool draws attention to the importance of engaging patients in decisions about their health by empowering them with the medical and economic information they need about treatment options. However, Drug Abacus was not designed to be used at the point of care.3

In order to provide an objective way to assess the benefits of new treatment options, alongside costs, the American Society of Clinical Oncology (ASCO) developed the Conceptual Framework to Assess the Value of Cancer Treatment Options (ASCO Value Framework). This framework was created with the ultimate goal of providing a standardized approach for physicians and patients to assess the value of new cancer therapies in comparison with established treatments.4

ASCO’s Value in Cancer Care Task Force developed the ASCO Value Framework around three critical elements, identified by the Institute of Medicine as components of high-value care: clinical benefit (efficacy), toxicity (safety), and cost (efficiency).4 These factors were chosen because they are readily measured, supported by high-quality medical evidence, and central to the mission of the clinical oncologist.4

In contrast with Drug Abacus, the ASCO Value Framework is designed to be used by oncologists, in conversation with their patients, so that patients can make informed choices about their treatment. Based on the available data on clinical benefits and side effects, a Net Health Benefit score is calculated for each new treatment in order to quantify the additional benefit gained by the patient from the treatment.4 The Net Health Benefit score is intended to be considered alongside the cost that would be incurred by the patient under that treatment approach. If successfully implemented, the use of the ASCO Value Framework would represent an individualized approach to cancer care that offers the best available therapy at the lowest achievable price.

Richard Schilsky, MD, FACP, FASCO, is the chief medical officer of ASCO, a highly respected leader in the field of oncology, and one of the key authors of the ASCO Value Framework. He spoke with Journal of Clinical Pathways about some of the forces that led to the development of the ASCO Value Framework and considerations that influenced its design.

The word “value” comes up a lot with regard to health care; how does ASCO’s Value in Cancer Task Force approach the concept of value for a particular cancer treatment?

By value, we mean a combination of clinical benefit, side effects, and cost. These three factors are important considerations for patients when weighing the pros and cons of different treatment options. That said, the value of a cancer treatment to a given patient is subjective and depends on the patient’s individual preferences, circumstances, and treatment goals. The ASCO Value Framework is intended to provide critical information to help patients make personalized treatment decisions with their physicians.

How does the ASCO Value Framework differ from other guidelines for determining what treatment approach to use? How does it differ from clinical pathways?

Whereas clinical practice guidelines in oncology serve as evidence-based guides for doctors and outline appropriate methods of treatment for specific areas of cancer care, and clinical pathways are detailed treatment plans for specific clinical scenarios (with different pathways being developed and adopted by a range of payers and health institutions), the ASCO Value Framework has been developed as the basis for a physician-guided decision-making tool for doctors to use directly with their patients, in the clinical setting, to discuss the relative value of new treatments as compared to established therapies while considering those treatments that are deemed by the physician to be appropriate options for the patient. The framework is intended to provide a starting point for a discussion between a doctor and a patient and should be used in tandem with clinical care guidelines and other tools to help guide high-quality patient care.

The ASCO Value Framework involves the calculation of a Net Health Benefit score, which should be considered alongside the treatment cost when making treatment decisions. Is there a reason why the cost of treatment was not incorporated into an overall total value score for each treatment? Why was it important to keep the net health benefit and the cost as separate considerations?

ASCO believes presenting the Net Health Benefit score and cost information side by side is a more useful way to facilitate a personalized value assessment between physicians and patients. It is important to have a clear measure of net health benefit, independent of cost considerations. At the same time, patients need to know how much a treatment will cost them so that they can make decisions based on their individual needs, goals, and financial preferences. The cost of treatment varies from patient to patient based on the terms of their insurance coverage, so it is simpler to present the Net Health Benefit score separately from the cost information.

Is there a concern that the use of such frameworks could prevent patients from receiving the best treatment personalized to their particular cancer?

The ASCO Value Framework is about weighing—not limiting—treatment options. Every patient should have access to the best treatment options as determined by the patient and his or her doctor. Our framework is about helping doctors and patients make well-informed decisions about care.

How can the methods used to create the ASCO Value Framework for cancer be applied to other treatment areas? Do you see a need for more value-based guidelines for treatment of diseases other than cancer? 

There is a move across medicine and from policy makers toward value-based care, driven by a concern over rising healthcare costs and a recognition that all patients deserve high-quality, high-value care. Improving cancer care is at the very core of ASCO’s mission and was a motivating factor in the development of the value framework.  A tool that could facilitate an informed conversation about treatment options between a doctor and patient could be useful in any specialty. 

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References

1.    Stowell, C, Akerman C. Better Value in Health Care Requires Focusing on Outcomes. Harvard Business Review. https://hbr.org/2015/09/better-value-in-health-care-requires-focusing-on-outcomes. Published September 17, 2015. Accessed September 25, 2015.

2.    Trends in Cancer Programs: Resources & Tools for the Multidisciplinary Team. ACCC Website. https://www.accc-cancer.org/surveys/pdf/Trends-in-Cancer-Programs-2015.pdf. Published 2015. Accessed September 25, 2015.

3.    Cavallo J. Calculating the Value of Cancer Drugs: A Conversation With Peter B. Bach, MD, MAPP. ASCO Post. 2015;6(15).

4.    Schnipper LE, Davidson NE, Wollins DS, et al. American Society of Clinical Oncology Statement: A Conceptual Framework to Assess the Value of Cancer Treatment Options. J Clin Oncol. 2015;33(23):2563-2577.