The cost of cancer care in the United States continues to rise, in part as a result of the aging population and improvements in diagnosis, treatment, and survival. These costs are projected to reach $173 billion in 2020, representing a 39% increase from 2010.1 Steadily increasing costs put pressure on payers and healthcare providers to develop innovative strategies to control costs. It is also increasingly recognized by various healthcare stakeholders, including providers, payers, and patient advocates, that the current reimbursement system needs refinement to adequately address the breadth of services that are involved in cancer care today.2,3 Furthermore, traditional fee-for-service payment models tend to reward volume and seldom support care coordination or the management of chronic disease. Bundled, risk-based, and episode-of-care−based payment systems have been evolving and are taking shape.4,5 The American Society of Clinical Oncology (ASCO) has undertaken steps to assist physicians with treatment decision-making, assessment of treatment value, and evaluation of quality of care.
To facilitate shared decision-making between physicians and patients, ASCO has developed tools designed to guide the assessment of comparative value of interventions. In 2015, ASCO released its value framework that provides a formula for calculating a drug’s net health benefit score based on clinical benefit and toxicity, which is then considered in conjunction with cost.6 Earlier, in 2013, ASCO released a list of 5 top tests, procedures, and treatments whose value is not supported by available evidence.7
ASCO identified potential barriers faced by oncologists in their ability to provide high-quality care while controlling costs for payers.8 These barriers include undue dependence of practice revenue on administration of drugs in the office; lack of incentive to prescribe less expensive drugs; lack of compensation for patient education and care coordination, including management of patient communications by telephone or e-mail or via a nonphysician member of the practice; insufficient compensation for initial visits, which may reduce access for new patients; lack of consideration of quality of care in providers’ compensation; and lack of compensation for clinical trial participation and management.8
In May 2014,8 ASCO released a proposal (which was revised in May 20159) titled the “Patient-Centered Oncology Payment: Payment Reform to Support Higher Quality, More Affordable Cancer Care,” consisting primarily of new payment types in exchange for practice accountability for delivering high-quality care.9
The new proposal involves 4 payment types, including (1) New Patient Treatment Planning ($750 per patient), (2) Care Management During Treatment ($200 per patient per month), (3) Care Management During Active Monitoring ($50 each month for each patient during treatment holidays and for up to 6 months after the end of treatment), and (4) Participation in Clinical Trials ($100 per month for each patient while treatment is underway and for 6 months afterward for trials in which practice support is not available).9
At the time of our study in 2014, a fifth payment was included in ASCO’s proposal, for Transition of Treatment (for treatment planning and patient education, when a patient begins a new line of therapy or ends treatment without an intention to continue).8 This item was removed from the revised proposal released subsequently by ASCO in May 2015.9
Billing for other services, including evaluation/management, chemotherapy infusions, advanced care planning, and testing/imaging, may be generated to the payer, as they currently are.9 In return for this proposed payment structure, the oncology practice would be accountable for delivering high-quality care, demonstrated by performance on several quality-of-care metrics, including emergency department visits and hospital admissions related to complications of treatment, following evidence-based guidelines for treatment patterns and end-of-life care, and following ASCO-defined quality standards.9
A provider payment reform that encourages multistakeholder engagement and rewards improvements in quality of care and patient outcomes while reducing costs may prove beneficial. The purpose of this present study was to assess the attitudes and perspectives of oncologists in the United States about the proposal, their level of support for the patient-centered oncology payment (PCOP), and to determine current use of quality-of-care metrics, factors influencing oncologists’ perception of the value of a new cancer drug, the influence of cost on treatment decision-making, and their perceptions of the overall reimbursement “climate” (ie, ease of billing payers for services and receiving appropriate payment) for their practice and patient case mix.
This study was undertaken to assess US oncologists’ perspectives on and support for ASCO’s payment reform proposal, and to determine their use of quality-ofcare metrics, factors influencing their perception of value of new cancer drugs, the impact of cost on treatment decisions, and the perception about reimbursement modalities.
Physicians and medical directors who specialize in medical oncology or hematology/oncology in the United States, who had practiced for at least 2 years, and managed the care of at least 20 patients with cancer were randomly invited, from a commercial online physician panel, to participate in a cross-sectional survey. The physician panel was created and maintained by a specialized third-party agency, and was designed to include a diverse set of physicians in a range of geographic and practice settings.
The physicians had given consent to be contacted to solicit their interest in participating in research using online data collection platforms. Invitations to participate in this research survey were sent to a random sample of oncologists in the existing panel. The physician and medical directors represented hospital-based and private practices in the United States.
The survey consisted of questions related to demographic and practice characteristics; factors shaping perceptions of value for new cancer drugs (namely, clinical efficacy, impact on quality of life, safety and tolerability, and cost-effectiveness); influence of treatment cost, payer reimbursement policies, and patient out-of-pocket costs when making prescribing decisions; perceptions of use of cost-effectiveness and comparative effectiveness data by payers when deciding reimbursement of drugs; opinions of the most pressing issues facing the future of oncology care in the United States; and level of support for each new payment and the value-based adjustments in ASCO’s proposal for PCOP.
Respondents were asked to identify the metrics they use to measure and track quality of care from the following list: Commission on Cancer (CoC) standards, patient satisfaction scores, Quality Oncology Practice Initiatives (QOPI), Physician Quality Reporting System (PQRS), adherence to clinical pathways, ASCO’s CancerLinQ, and other metrics (ie, metrics from the National Accreditation Program for Breast Centers, American College of Radiology, or any homegrown dashboard).
Questions related to influence of the overall drug costs and patient out-of-pocket drug costs on prescribing decisions were adopted from a survey conducted by Neumann and colleagues in 2010.10 Each component of the ASCO proposal was described briefly in the survey, using text from the PCOP. The survey also solicited unstructured verbatim feedback on the ASCO proposal.
The survey required approximately 15 minutes to complete, and the respondents were assured of anonymity and confidentiality. No personally identifiable information was collected. The respondents were compensated nominally, per fair market value, for their time to complete the survey. The study was conducted between July and November 2014.
Study results were analyzed descriptively, with unadjusted statistical differences between groups assessed using chi-square tests for discrete variables and t-tests for continuous variables. Logistic regression models were constructed to assess factors supporting each of the main payment models described in the payment reform proposal. P values of less than .05 were considered significant in all analyses.
A total of 231 physicians (oncologists or hematologists) and medical directors responded to the invitation and completed the survey. Characteristics of the respondents and their practices are listed in Table 1. Medical directors accounted for 13.0% of the respondents. Approximately two-thirds (67.5%) of respondents specialized in hematology/oncology and 32.5% in medical oncology. The average duration of physicians’ practice was 15.3 years; 59.3% of the participants were aged 30 to 49 years.
Slightly more than half (53.2%) of the participants practice in an academic, community, or Veterans Administration (VA) hospital; 46.8% are part of a group or solo private practice; 40.7% participate in an accountable care organization (ACO); and 88.7% use electronic health records (EHRs). Only 6.9% of the participants rated the current reimbursement climate as “excellent,” and only 18.2% rated the financial status of their practice’s cancer program as “excellent.”
Participants who rated the overall financial status of their cancer program as excellent or good had practiced for fewer years than those who rated it otherwise (14.1 vs 17.1 years; P = .0069); males were more likely than females to rate it as excellent or good (62.3% vs 42.5%; P = .0206). Medical directors were more likely than physicians to rate the overall reimbursement climate as excellent or good (60.0% vs 35.3%; P = .0096), as were participants whose cancer programs have a contract with a commercial payer that reimburses for dispensed oral cancer drugs (48.0% vs 31.0%; P = .0083). Physicians who rated the reimbursement climate favorably had a larger mean volume of patients per physician (748 vs 370 patients; P = .0004).
Use of Quality-of-Care Metrics
The most common quality-of-care metric used by respondents was patient satisfaction scores (60.1%), followed by QOPI (42.9%), adherence to clinical pathways (35.5%), PQRS (34.6%), CoC standards (23.8%), other (10.8%), and CancerLinQ (2.6%); 13.0% stated that no quality-of-care metrics were used or “not sure” (Table 2).
Overall, 81.4% of respondents stated that their organization’s quality measurement and tracking procedures were “somewhat” or “highly” effective in terms of improving quality of care, outcomes, and cost-savings. On average, physicians reported that they followed the National Comprehensive Cancer Network guidelines/pathways for an average of 76.4% of their patients; 84.2% of their patients reportedly had documented clinical/pathologic staging before initiation of treatment (86.8% among non-ACO respondents vs 80.3% among ACO respondents; P = .0389). The use of at least 1 metric was more common among respondents participating than those not participating in an ACO (92.6% vs 83.2%; P = .0380). The use of patient satisfaction scores was more common among respondents using than those not using EHRs (62.4% vs 42.3%; P = .0482).
Perception of Value of a New Cancer Treatment
On a scale of 1 to 4, with 1 being the most important and 4 being the least important, respondents ranked clinical efficacy as the most important factor when considering the value of a new cancer drug (mean score, 1.4), followed by impact on quality of life (mean score, 2.69), safety and tolerability (mean score, 2.71), and cost-effectiveness (mean score, 3.2; Figure 1).
Perception of Oncology Care Landscape
The cost of cancer drugs reportedly influenced prescribing decisions “quite a bit” or “a lot” for 28.1% of participants; patient out-of-pocket costs were said to influence prescribing decisions “quite a bit” or “a lot” for 48.5% (Figure 2). In addition, 37.7% of participants reported that payer reimbursement policies limited their ability to offer certain therapies to their patients “quite a bit” or “a lot.”
Overall, 26.8% and 22.1% of the respondents rated the use of cost-effectiveness and comparative effectiveness data, respectively, by payers for reimbursement decisions as negative or neither positive nor negative.
According to the survey results, the most pressing issues facing oncology care today are increasing costs of drug prices (69.3%), growing demand for cancer care services (56.7%), and cost and payer pressures (53.3%), provider burnout (38.1%), and anticipated workforce shortages (27.7%) (Table 2).
Support for Proposed New Payments
Approximately half of the respondents “strongly” or “somewhat” supported the proposed payments in the PCOP (Figure 3).9 New Patient Treatment Planning payments were strongly or somewhat supported by 46.7%; Care Management During Treatment payments by 57.2%; Care Management During Active Monitoring payments by 54.5%; Transition of Treatment payments by 54.1%; and Participation in Clinical Trials payments by 74.9%. Support for the payments was stronger for respondents who rated the overall reimbursement climate as “excellent” or “good” than for those who rated it “satisfactory,” “not very good,” or “bad” (Figure 4).
Among those who rated the reimbursement climate as excellent or good (vs those who rated it otherwise), 55.1% supported New Patient Treatment Planning payments (vs 41.6%; P = .0452); 66.3% supported Care Management During Treatment payments (vs 51.4%; P = .0261); 65.2% supported Care Management During Active Monitoring payments (vs 47.9%; P = .0103); 60.7% supported Transition of Treatment payments (vs 50.0%; not significant); and 73.0% supported Participation in Clinical Trials payments (vs 76.1%; not significant). Support for all proposed payments was marginally higher among respondents who rated the financial status of their organization’s cancer program as excellent or good compared with those who rated it as satisfactory, not very good, or bad; however, the difference was not significant.
Logistic regression analysis using backward elimination was performed to assess factors contributing to support (strongly/somewhat support vs neutral or strongly/somewhat oppose) for each main payment type described in the reform proposal. The characteristics considered in this analysis are listed in the Appendix (see end of article).
The logistic regression analysis showed that male respondents generally reported greater support for the new payments than female respondents, including New Patient Treatment Planning payments (odds ratio [OR], 2.4; P = .0259); Care Management During Treatment payments (OR, 3.6; P = .0010); Care Management During Active Monitoring payments (OR, 2.1; P = .0389); and Transition of Treatment payments (OR, 2.2; P = .0263).
Respondents having a contract with a commercial payer that reimburses for dispensed oral cancer drugs were more likely to support the proposed payment types than others, including New Patient Treatment Planning (OR, 2.6; P = .0006); Care Management During Treatment (OR, 1.9; P = .0388); Care Management During Active Monitoring (OR, 1.8; P = .0391); and Transition of Treatment (OR, 1.9; P = .0232).
Race (white vs nonwhite) was a significant factor for supporting payments for Care Management During Treatment (OR, 1.9; P = .0283) and Care Management During Active Monitoring (OR, 1.8; P = .0487). Respondents who practice in an academic/community hospital or VA facility were more likely than those in group/solo practice to support payments for Care Management During Treatment (OR, 2.0; P = .0216) and Participation in Clinical Trials (OR, 2.0; P = .0218). Respondents who use EHRs were more likely to support payments for Participation in Clinical Trials (OR, 2.4; P = .0466).
Support for Accountability for Quality of Care
Accountability for delivering high-quality, evidence-based, patient-centered care, with payments slightly increasing or decreasing based on quality metrics, was supported by 74.9% of respondents. Respondents who practice in an academic, community, or VA hospital were twice as likely as those in group or solo private practice to support accountability for quality of care (81.3% vs 67.6%; OR, 2.1; P = .0176).
Value-based adjustments were supported by approximately 50% of the respondents. Specifically, 54.6% strongly or somewhat supported rating oncology practices based on the degree of collection and reporting key standard quality measures and performance against benchmarks; 52.4% strongly or somewhat supported rating oncology practices based on level of use of existing pathways and adherence to pathways over time; and 45.9% supported rating practices based on patients’ risk-adjusted rates of oncology-related emergency visits. (Value-based adjustments were not included in the May 2015 revision of the PCOP.)
At the end of the survey, respondents were asked to provide qualitative feedback on ASCO’s PCOP, including their overall thoughts, whether they disliked any components of the proposal and the reasons for this, and whether there are any areas for improvement. A thematic analysis of the qualitative responses was conducted to determine whether they responded generally positively, negatively, neutrally, had no opinion, or were unsure or needed more information on the overall proposed payment-reform policy and its different components.
Overall, 210 (90.9%) respondents provided qualitative feedback; 49.5% responded generally positively regarding the PCOP, 30.5% were unsure or neutral, and 20.0% felt generally negatively about the policy. The top reasons for feeling generally positively related to the proposal’s ability to control costs and to standardize measurements of quality of care in oncology. Some of these respondents felt that the proposal does not go far enough to rein in costs of drugs and imaging procedures, but generally thought that it is a step in the right direction.
The top reasons for a generally negative attitude toward the policy related to perceived lack of consideration of the complexity of treating individual patients, and lack of focus on reimbursement for diagnosis and initiating care for patients who continue their care with a different practice subsequently. Some respondents noted that the ASCO proposal could make it difficult to remain in private practice, or that it would affect patients’ ability to access newer treatments.
Our research reveals that support for the ASCO PCOP is generally mixed, with a greater level of support coming from oncologists who already consider the current reimbursement climate or the current financial status of their practice to be positive. However, nearly 75% of the respondents appeared to appreciate the need to be held accountable for delivering high-quality, evidence-based, patient-centered care. Despite such views, only approximately 50% of the sample supported value-based adjustments that involve rating practices based on their performance against benchmarks, adherence to treatment pathways, and risk-adjusted rates of oncology-related emergency visits. Thus, it is not surprising that these value-based ratings were removed from the 2015 version of the PCOP proposal.
Although more than 80% of respondents stated that the standard quality-of-care measures used by their oncology practice were somewhat or highly effective in improving quality of care, outcomes, and cost-savings, the established metrics for quality of care generally are underutilized. Patient satisfaction scores were not used consistently, even in sites without an EHR system, and more than 10% of respondents were not aware of any quality-of-care metrics used by their practice.
These findings reinforce the need for improving the evaluation of quality of care in oncology to strengthen care delivery and outcome evaluation. Various efforts may pave the way for better implementation and reporting of quality metrics, including the proliferation of ACOs; regulations set forth by the Centers for Medicare & Medicaid Services (CMS), which require ACOs to meet specific quality performance standards to participate in the Shared Savings Program; and interactions between ACOs’ quality reporting and other CMS initiatives, particularly the PQRS, Physician Value-Based Payment Modifier, and the EHR Incentive Program.11
These efforts may further influence the support for, and adoption of, effective payment reforms such as ASCO’s PCOP, which ties payment to performance. However, for oncology practices that remain unaffiliated with ACOs, an appropriate incentive and support structure must be enacted to encourage adoption of relevant quality metrics and reporting among these practices.
Increasingly, oncology practices are burdened with administrative hurdles to providing quality care to cancer patients while maintaining the financial stability of their practice.2 This is supported by our respondents’ input on the key issues facing the future of oncology care in the United States, namely, cost and payer pressures; increasing drug prices; growing demand for cancer services; provider burnout; and workforce shortages.
Overall, 28% of respondents identified the cost of drugs as a key influence on their prescribing decisions. A similar proportion (27%) rated drug cost-effectiveness as “1” or “2” on a scale of 1 (most important) to 4 (least important) while rating the factors that constitute “value” for a new cancer drug; 48% of respondents reported patient out-of-pocket costs as another key factor influencing their prescribing decisions. These views are consistent with the ongoing debate on shifting more of the economic burden to patients.12-15
Empowering practices with up-to-date information on care modalities, clinical pathways, and payer reimbursement, while recognizing and compensating for the complexity of individualized oncology care delivery, may help sustain the viability of oncology practices in the United States, and community practices in particular. Finally, an optimal payment-reform model should address the diverse needs of provider stakeholders in the United States.
Although the random sample of oncologists was from across the United States, encompassing academic and community-based practices, the oncologists who chose to respond to our survey may differ from those who did not.
An online survey has several limitations. Physicians who participate in online panels and complete online surveys tend to be young; 27% of respondents in this study were aged <40 years, whereas the 2014 oncology practice census data from ASCO reported only 16% of oncologists aged <40 years.16
In addition, compared with 2014 national averages of practice census data reported by ASCO,16 our study had a higher proportion of female respondents, oncologists who practice in an academic or university setting, and ACO participants.
Furthermore, ASCO membership status was not assessed in our study. It is possible that such affiliation could have influenced respondents’ perceptions of the ASCO payment reform proposal.
Through this study, we attempted to describe the views of real-world practicing oncologists toward a payment reform proposal that would have implications on their daily practice. These results reflect mixed support for the proposal, underscoring the importance of continuous and broader engagement of practicing physicians from diverse settings around the country via outreach and dialogue on topics that affect their clinical practices, as well as education and awareness activities from ASCO and other policy-shaping organizations to their constituents.
Author Disclosure Statement
The authors did not receive any financial support for this study. Mr Narayanan has received research grants from GlaxoSmithKline, Vertex, Sun, Celgene, Johnson & Johnson, Teva, and Bayer. Ms Hautamaki has received research grants from Vertex, Merck, Sun, Celgene, and GlaxoSmithKline.
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