The recently concluded 50th annual meeting of the American Society of Clinical Oncology (ASCO) included an “extended education” session in which representatives of different “stakeholder” perspectives sought common ground on trying to define what constitutes value in cancer care. While cancer care is multidisciplinary, ASCO is largely an association of medical oncologists, and, indeed, the meeting is dominated by news of new drugs and new drug clinical trials, so the emphasis of this particular session tended toward the issues of how to decide what new drugs are worth, to whom, and how to pay for them.
There were too many points for a single blog post, and the only clear point of agreement is that good medical practice and treatments that actually provide value for patients should be delivered by doctors and considered worth paying for by patients, society, and payers. But that’s like saying that “good should be done and evil avoided”—true, but it doesn’t get us very far. ASCO is sponsoring a substantial initiative to develop consensus among its leadership and broader membership about what the cancer doctors consider valuable about drugs in particular. The focus here is on spending less time, effort, and money on developing, much less prescribing, drugs that have, or are destined to have, only marginal efficacy (e.g., prolonging life for less than a couple of months on average). Already, ASCO has identified a “top 5 list” of wasteful practices, as part of the American Board of Internal Medicine’s “Choosing Wisely” campaign, but even that seems sort of obvious. For example: don’t do PET scans for someone in remission without symptoms, unless there is good reason (strong evidence) that it will make a difference. I bet following that would eliminate only a small fraction of expensive imaging tests. And the initiative, while useful, is entirely from the physician’s point of view. Perhaps it is just too hard to do the kind of highly sophisticated, patient-centered preference investigations that I have heard described for other areas of medicine, like autoimmune disease, but no such investigations were discussed in the ASCO meeting session.
Of particular interest was a comparison of two working definitions of value. One comes from Prof. Michael Porter of Harvard Business School, who has said that value in medicine is defined by results for patients, and “the creation of value for patients should determine the rewards for all other actors in the system.” The second is from Dr. Scott Ramsey of the University of Washington Medical Center, who has described value in medicine as a set of outcomes that can be agreed upon by all stakeholders. The ASCO session speakers smiled on the former statement, which seems better to me, but the session structurally embraced the latter, which may be a practical necessity for policy but which seems to make the patient peripheral to the whole discussion. There was no serious time devoted to a careful examination of these two definitions of value.
The session was anchored by the irrepressible, indefatigable Dr. Emanuel, who scolded the members of the audience for practicing wasteful medicine to line their own pockets—bold, as might have been expected from the speaker but perhaps a bit surprising from someone a bit more removed from direct patient care than the listeners he was addressing. Surely, some reimbursement policies have encouraged use of expensive drugs, and some physicians may be too susceptible to incentives that compete with the patient’s interest, but I get the impression that profiteering is a lot harder in private practice oncology than may be perceived, and other factors increase costs. (For example, chemotherapy is a lot more expensive when given in a hospital than when given in a private office.) And the rhetoric was jarring, and not very effective. No appeal to the proper goals of medicine and “the better angels of our nature,” if you will. Remember the old story of the contest between the sun and the wind to see which could get the man to remove his coat? This was the wind.
Again, there were too many points to cover here in a single post, and the perspectives from the insurance and pharmaceutical industries demand separate treatment—subjects for future posts.