In the face of limited health care resources and a rising national health budget, it is important to consider value when making treatment decisions for patients with cancer. This is a key question for all of us involved in cancer care and research. The answer may be a bit different coming from the viewpoint of the different stakeholders. One of my favorite quotes is from fellow Omaha native Warren Buffett “Price is what you pay. Value is what you get.” Let’s evaluate the different viewpoints on value in cancer care:
1. Patients: As health care providers, we think that value of cancer care for a patient is the same as what we consider, such as increased time without evidence of the cancer associated with the lowest cost of care. However, patient interviews demonstrate an alternative viewpoint. A survey of 769 patients with metastatic breast cancer were asked to define value in cancer care. Many of the responses defined this as “information and appropriate communication of information in the right time and place,” or “the amount of time spent with the physician or medical team.” On the other hand, only 7.4% of the patients defined value in an economic context. An example of these comments would be “value in cancer treatment is getting the best options at the lowest cost, presented to you in a manner that is easily comprehended”. Many more of the responses related to value centered around quality of life and feeling well enough to engage in meaningful functions.1 This is a view of value that is much broader than most of the health care system might think of when we use the term “value in cancer care.”
2. Physicians: Cancer care providers want to administer the treatments that give the best clinical outcome with the most manageable toxicities at the lowest cost. However, critical information is needed to gather the specifics to analyze the data to provide the evaluation. There is always a concern about oncology therapies to be sure that the balance between the additional cost and possible toxicities are balanced with the clinical improvements. What constitutes a meaningful improvement in the clinical outcome to warrant what additional cost? As physicians we often lean on the side of improvement in outcomes without specifically thinking about the additional costs to the patient or the health care system and society. We may need to consider a more balanced approach.
3. Health Insurers/Society: Companies or the government who have the perspective of a larger population are often caught between the patient and physician who want access to every treatment and the newest technology and employers or funders of the insurance who demand that the health care funds are spent with the highest value care in mind. Insurers have developed guidelines, pathways, and tools to use evidence-based medicine for cancer care. We need to balance the options for therapy with the potential for improvement in the patient’s disease control and quality of life. The involvement of cancer specialists and patient advocates in the development of treatment strategies and pathways are key to successful programs that are a coordinated effort.
A combined statement of value in cancer care might be defined as patients, families, physicians, health care institutions and health insurers all agreeing that the benefits afforded by the interventions are sufficient to support the total sum of resources expended for its use. If all parties can agree on what constitutes value in cancer care, the pathway forward would be much clearer for all stakeholders.
- Survey results presented at the 5th Annual Conference of the Association for Value-Based Cancer Care.