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Workshop Summary INTRODUCTION Rising health care costs are a central fiscal challenge confronting the United States (CBO, 2012b; IOM, 2012a; Sullivan et al., 2011). National spending on health care currently accounts for 18 percent of gross domestic product (GDP), but is anticipated to increase to 25 percent of GDP by 2037 (CBO, 2012a). The Bipartisan Policy Center argues that “this rapid growth in health expenditures creates an unsustainable burden on America’s economy, with far-reaching consequences” (BPC, 2012). These conse- quences include crowding out many national priorities, including invest- ments in education, infrastructure, and research; stagnation of employee wages; and decreased international competitiveness (BPC, 2012; Emanuel et al., 2012; Milstein, 2012). In spite of health care costs that far exceed those of other countries, health outcomes in the United States are not con- siderably better (Fineberg, 2012; IOM, 2010b, NRC and IOM, 2013). In fact, the United States is in the lowest quartile for life expectancy among countries in the Organisation for Economic Co-operation and Develop- ment (OECD) (Fineberg, 2012). The costs of cancer care are expected to increase as the aging of the population leads to a rapid influx of new cancer diagnoses and as new innovations in cancer treatment and care are deployed in practice. As more expensive targeted therapies and other new technologies in surgery and radiation become the standard of care, there are concerns that the costs of 1

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2 DELIVERING AFFORDABLE CANCER CARE IN THE 21st CENTURY cancer treatment could begin to outpace health care inflation as a whole (Sullivan et al., 2011). Advances in early detection, prevention, and treatment have resulted in consistently falling cancer death rates (Eheman et al., 2012). Compared to other OECD countries, the United States has a lower cancer mortality rate for males and a similar cancer mortality rate for females (OECD, 2013). However, many indications suggest that cancer care is not optimal. Despite progress in reducing cancer death rates, disparities in cancer outcomes persist, problems of overuse and misuse contribute to a lack of evidence- based cancer screening and treatment, and many patients do not experience patient-centered cancer care, such as access to palliative care and use of treatment plans to help with patient–clinician communication and decision making (Goodwin et al., 2011; IOM, 2011; Schnipper et al., 2012; Siegel et al., 2011). In addition, there are missed opportunities to collect information that could help inform clinical practice decision making (IOM, 2012a), as electronic medical records (EMRs) are often not designed for this purpose. With the goal of ensuring that patients have access to high-quality, affordable cancer care, the Institute of Medicine’s (IOM’s) National Cancer Policy Forum convened a public workshop, Delivering Affordable Cancer Care in the 21st Century, October 8–9, 2012, in Washington, DC.1 Work- shop presentations and discussions examined the drivers of current and projected cancer care costs, including • inappropriate financial incentives in the health care system; • unrealistic expectations about the effectiveness of screening and  treatments for cancer by both patients and clinicians; • overuse and misuse of medical resources and inadequate adherence  with treatment guidelines; and • lack of evidence on what represents high-quality, affordable cancer  care. 1This workshop was organized by an independent planning committee whose role was limited to the identification of topics and speakers. This workshop summary was prepared by the rapporteurs as a factual summary of the presentations and discussions that took place at the workshop. Statements, recommendations, and opinions expressed are those of indi- vidual presenters and participants, are not necessarily endorsed or verified by the Institute of Medicine or the National Cancer Policy Forum, and should not be construed as reflecting any group consensus.

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WORKSHOP SUMMARY 3 Workshop participants also suggested ways to improve the affordability and quality of cancer care. Box 1 highlights possible solutions proposed by individual participants. Beginning on page 29, the workshop summary describes possible solutions in more detail, organized by: • patient and clinician communication and education • best practices in cancer care • evidence base for clinical practice and reimbursement • financial incentives aligned with affordable, high-quality cancer care • delivery system and reimbursement changes A recurring theme of the workshop was the need for all stakeholders— including patients, clinicians, private and government payers, and the phar- maceutical and device industries—to work together to address affordable cancer care. In addition, several workshop speakers suggested that strategies for controlling cancer care costs are likely to be applicable to reducing health care costs in general. “Because cancer is such a prevalent set of conditions and so costly, it magnifies what we know to be true about the totality of the health care system. It exposes all of its strengths and weaknesses,” explained Susan Dentzer, editor in chief at Health Affairs. Mark McClellan, director of the Engelberg Center for Health Care Reform at the Brookings Institution, concurred, adding, “Oncology is where the action is going to be. There will be modifications called for in the Affordable Care Act that will put more pressure on finding ways to lower cancer care costs while improving quality and innovation.” IOM President Harvey Fineberg agreed: “If we can find a way to solve this problem for cancer care, then we have the keys to solve it for health care more broadly.” Workshop presentations and discussions will also inform an ongoing IOM consensus study, Improving the Quality of Cancer Care: Addressing the Challenges of an Aging Population. The study committee is examining issues in the quality of cancer care, including a specific focus on how the aging of the population will rapidly accelerate the number of new cancer diagnoses at a time when workforce shortages are predicted. The committee’s report is expected to be released in 2013. A FINANCIAL CRISIS IN HEALTH CARE Workshop speakers presented statistics that underscore the severity of the problem of health care spending and the need for immediate solutions.

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4 DELIVERING AFFORDABLE CANCER CARE IN THE 21st CENTURY BOX 1 Possible Solutions to Improve the Affordability and Quality of Cancer Care Highlighted by Individual Participants • mprove the information patients have to make decisions about I and manage their care o  ake available transparent quality metrics to help patients M select their oncology providers o eimburse clinicians for communications with patients, R including provision of accurate information on a patient’s prognosis; the costs, potential benefits, and side effects of various treatment options; and palliative care and hospice care considerations • mprove training and information available to clinicians I o nsure clinicians are well trained to communicate with E patients, follow evidence-based guidelines, and convey the financial repercussions of different treatment options o romote adherence to the American Society of Clinical Oncol- P ogy Top 5 list and encourage clinicians to stop using interven- tions with questionable value o  Incorporate cost information in clinical practice guidelines and treatment pathways • Promote and facilitate best practices in cancer care o upport team-based models of care that provide 24-hour sup- S port to cancer patients o nsure early integration of palliative care in cancer care deliv- E ery and better use of hospice care The total cost of health care in the United States is currently about 18 per- cent of GDP. By 2037, total health care expenses are expected to account for 25 percent of the U.S. GDP (CBO, 2012a). “We really don’t have a choice in terms of reducing the amount of money we spend on health care. We have to face this problem,” stressed Scott Ramsey, full member of the Fred Hutchinson Cancer Research Center and professor of medicine at the University of Washington. The United States spends far more than other nations on health care, in proportion to its earnings as a nation (see Figure 1). “We are on a dif- ferent planet,” said Ezekiel Emanuel, Diane v.S. Levy and Robert M. Levy University Professor and vice provost for Global Initiatives at the University of Pennsylvania.

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WORKSHOP SUMMARY 5 o  Improve the functionality and interoperability of electronic medical records o rovide feedback to patients, providers, and payers through P population-based performance measurement of quality, out- comes, and costs • Enhance research that informs clinical practice o evelop learning health care systems to collect point-of-care D data that can inform personalized medicine, comparative effectiveness, health care redesign, and quality cancer care o onduct pragmatic trials with real-world comparators and C populations, as well as clinically relevant outcomes in perti- nent patient subpopulations •  eward the provision of affordable, high-quality cancer care R through delivery system and reimbursement changes o valuate delivery system changes, including capitation, E episode-related payments, medical homes, accountable care organizations, and shared savings programs o upport coverage with evidence development programs to S assess new innovations in cancer care o eimburse clinicians for performance on quality measures R and for patient–clinician communication o ever the relationship between treatment choice and physi- S cian income o tructure copayments based on the value of the service pro- S vided, to encourage patients to use higher-value treatments and discourage use of lower value interventions Despite spending nearly twice as much on health care as many other developed countries, the United States is not reaping more benefits in terms of increasing life expectancy or lowering infant mortality, said Ramsey and Otis Brawley, the chief medical officer and executive vice president of the American Cancer Society (see also Fineberg, 2012; OECD, 2013). For example, the U.S. life expectancy is slightly lower and its infant mortality rate slightly higher than that of Canada or Switzerland (OECD, 2011, 2013), despite lower health care expenditures in both countries compared to the United States (OECD, 2011). “We don’t get what we pay for, even though we are the most expensive health care system in the world,” Brawley said. Brawley noted that the $2.6 trillion spent on health care in the United States is more than twice what the nation spends on food. Emanuel added

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6 DELIVERING AFFORDABLE CANCER CARE IN THE 21st CENTURY Health expenditure per capita (USD PPP) 8,000 USA 7,000 6,000 5,000 NOR CHE DNK BEL CAN LUX 4,000 DEU AUT NLD FRA ISL SWE IRL 3,000 GRC ESP GBR AUS NZL FIN ITA JPN PRT 2,000 SVK KOR HUN CZE 1,000 MEX POL TUR 0 10,000 20,000 30,000 40,000 50,000 60,000 GDP per capita (USD PPP) FIGURE 1  Total health expenditure per capita and gross domestic product per capita, 2007. The United States spends far more per capita on health care than the other Organ- isation for Economic Co-operation and Development countries. NOTE: AUS = Australia; AUT = Austria; BEL = Belgium; CAN = Canada; CHE = Switzerland; CZE = Czech Republic; DEU = Germany; DNK = Denmark; ESP = Spain; FIN = Finland; FRA = France; GBR = United Kingdom; GDP = gross domestic p ­ roduct; GRC = Greece; HUN = Hungary; IRL = Ireland; ISL = Iceland; ITA = Italy; JPN = Japan; KOR = Korea; LUX = Luxembourg; MEX = Mexico; NLD = Netherlands; NZL = New Zealand; NOR = Norway; POL = Poland; PPP = purchasing power parities; ­ PRT = Portugal; SVK = ­ lovak Republic; SWE = Sweden; TUR = Turkey; USA = United S States; USD = U.S. dollar. SOURCES: Emanuel presentation (October 8, 2012) and OECD, 2009, Health at a Glance 2009: OECD Indicators, OECD Publishing. http://dx.doi.org/10.1787/ health_glance-2009-en (accessed March 6, 2013). that about one-third of health care costs are hospitalization expenses— which is more than the United States spends on Social Security ($731 billion) or defense ($718 billion) (CBPP, 2012; KFF, 2009). Such high spending on health care affects other aspects of the nation’s economy and welfare. Emanuel argued that these rising health care costs jeopardize health coverage and access; state budgets and funding for education; middle-class wages; and the United States’ long-term fiscal stability and status as a world power. Emanuel noted that one state budget director predicted Medicaid

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WORKSHOP SUMMARY 7 and other health care expenses would grow by as much as 40 percent of the state budget by 2015, forcing the state to cut higher education funding. Wages are also linked to health care costs, with increasing costs caus- ing employers to balance their budgets by lowering wages (Emanuel and Fuchs, 2008). Lee Newcomer, senior vice president of oncology for UnitedHealthcare, added that one recent projection suggested that in 2017, health insurance premiums and out-of-pocket health costs could account for half of all household income (see Figure 2). Household Income 50% of Household Income Family Health Insurance Premiums Family Premium + OOP Costs $120,000 $110,000 $100,000 $90,000 Household Income $80,000 $70,000 $60,000 $50,000 $40,000 $30,000 $20,000 $10,000 $0 2000 2005 2010 2015 2020 2025 2030 2035 Year FIGURE 2  Projected annual family health insurance premium costs and average house- hold income in the United States. NOTE: OOP = out-of-pocket. SOURCES: Newcomer presentation (October 9, 2012) and Young and DeVoe, 2012. Reprinted with permission from Who Will Have Health Insurance in the Future? An Updated Projection, March/April, 2012, Vol 10, No 2, Annals of Family Medicine. C ­ opyright © 2012 American Academy of Family Physicians. All Rights Reserved.

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8 DELIVERING AFFORDABLE CANCER CARE IN THE 21st CENTURY The impact of health care costs on the overall economy is substantial, Ramsey stressed, quoting the Stanford health economist Victor Fuchs: “If we solve our health care spending, practically all of our fiscal problems go away. [If we don’t,] then almost anything else we do will not solve our fiscal problems” (Kolata, 2012). The urgency of the health care financial crisis and the need to solve it was stressed by several speakers. “We have to do something in the very immediate future about this,” Newcomer said. “We do not have time to do a long controlled study about it any longer.” McClellan added, “We can’t keep doing things the way that we have been doing them because it is not financially sustainable. And if you look at the trends in health care costs, we don’t have 5 years to wait and see what works. We need something sooner.” Emanuel warned, “We don’t have a lot of time and we need to be proactive. Now is the time to take a risk.” Drivers of Health Care Costs Fineberg stressed that total health care costs must be addressed, and that shifting costs to insurers, hospitals, providers, patients, or the govern- ment will not solve the problem of unsustainable health care costs. “It does not make sense to drive only toward making health care affordable for the person, affordable for the government, affordable for the employer,” said Fineberg. “If we are going to succeed in reaching affordable cancer care and an affordable health care system, we have to focus on the total costs.” Emanuel attempted to dispel some common misperceptions about the drivers of escalating health care costs. He said physicians tend to blame much of the rising costs on the practice of defensive medicine,2 medical malpractice, insurance company profits, drug costs, and demanding patients. However, Emanuel pointed out that malpractice premiums, settlements, and administrative costs compose slightly more than 1 percent of health care spending, with defensive medicine estimated at 2.5 percent of total health care spending. Additionally, proposed tort reforms are estimated to reduce health care spending by only 0.5 percent (CBO, 2009). Similarly, the profits of the five biggest health insurers in 2010 was $11.7 billion, which he called “a drop in the bucket” of total health care spending (Emanuel, 2011). There 2Defensive medicine occurs when doctors order tests, procedures, or visits, or avoid high-risk patients or procedures, primarily (but not necessarily or solely) to reduce their exposure to malpractice liability (OTA, 1994).

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WORKSHOP SUMMARY 9 also is no evidence that particularly demanding patients are driving up the costs of care substantially. Patients who use more than $1 million in health care services composed only 0.5 percent of total health care spending, and those who use more than $250,000 compose 6.5 percent, according to Emanuel. However, Emanuel noted that 10 percent of the population spends more than 60 percent of our nation’s health care costs (KFF, 2009). “These are patients with multiple chronic illnesses and cancer, and that is who we have to focus on if we really want to control costs,” Emanuel said. Speak- ers discussed other drivers of rising health care costs, including financial incentives driven by fee-for-service reimbursement that reward volume of care rather than quality or efficiency of care, and a lack of focus on system and individual patient costs of treatment. Additionally, innovation and the diffusion of new technologies in care and a lack of coordination among providers, hampered by a lack of interoperability of EMRs, have also led to high health care costs. Throughout the workshop, Emanuel and other speakers stressed that the complex reasons for these high costs necessitate a multifaceted solution. “The fault in the health care system lies with the doctors, hospitals, govern- ment, insurers, lawyers, patients, and their advocacy groups. There is no one who is not to blame for the problem in American health care,” Brawley said. Thomas Kean, chief executive officer and president of C-Change, added, “We all are the problem. The demonizing doesn’t really take us anywhere because we are all part of the solution.” Cancer Care Costs Total cancer care costs are estimated to comprise 5 percent of all health care expenditures and 10 percent of Medicare expenditures (ACS CAN, 2009; Sullivan et al., 2011). Robin Yabroff, an epidemiologist at the National Cancer Institute, reported that the estimated medical costs of cancer care were $125 billion in 2010, but costs are projected to increase to $173 billion in 2020, a 39 percent increase (Mariotto et al., 2011). How- ever, she pointed out that there are numerous challenges for estimating and projecting cancer costs, including a lack of complete data, especially the costs for uninsured patients, as well as unanticipated changes in treatment practices that can significantly affect cost projections. Emanuel said that due to these challenges, both current and projected estimates in cancer care costs are probably underestimates.

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10 DELIVERING AFFORDABLE CANCER CARE IN THE 21st CENTURY Emanuel emphasized that although cancer patients represent 0.6 percent of the population, they accrue 5 to 6 percent of the total health care expenditures. Newcomer added that 11 percent of UnitedHealthcare’s budget accounts for cancer care—half is attributed to hospitalization costs, while the remaining half is split almost evenly between the costs of physi- cians and the cost of cancer drugs. Leaders from the cancer community reviewed the evidence on inter- national cancer costs to compose a public policy perspective on deliver- ing affordable cancer care in high-income countries for Lancet Oncology, reported Jeffrey Peppercorn, associate professor of medicine at Duke Uni- versity and faculty associate of the Trent Center for Bioethics. These authors concluded that both the burden of cancer and the costs of cancer care are continuing to increase for high-income countries (Sullivan et al., 2011). He added that in the past 30 years, the cost of cancer care in the United States has increased substantially. Many speakers discussed the drivers of increasing cancer care costs, including innovation and technology diffusion; overuse and misuse of interventions; an insufficient evidence base to inform clinical decision mak- ing; regulatory and legal issues; increasing drug prices; and demographic and epidemiologic trends, including an aging population and an obesity epidemic, that are increasing the incidence of new cancer diagnoses. Ramsey noted from 2010 to 2030, total projected cancer incidence is estimated to increase by 45 percent (Smith et al., 2009). According to Peppercorn, the median age at diagnosis for all cancers is 66 years (SEER, 2012), and between 2010 and 2050, the number of Americans aged 65 and older is projected to double—from 40.2 million in 2010 to 88.5 million in 2050 (U.S. Census Bureau, 2010). Many cancers are also turning into chronic diseases that require use of more care over a patient’s lifetime, Ramsey said, further contributing to a rise in cancer care costs. Given the link between obesity and the risk of developing a number of different cancers and other chronic diseases (IOM, 2012b), the grow- ing obesity epidemic is expected to be a driver in rising cancer care costs, P ­ eppercorn and Brawley emphasized. Brawley noted that in the past 30 years, the obesity rate in adults has doubled, and the childhood obesity rates have more than tripled (IOM, 2012d). Another driver of cancer care costs are cancer drugs, due in part to the increasing unit prices of cancer drugs (Bach, 2009; see Figure 3). Medicare spending on such drugs has been rising steadily over the past few decades, noted Peter Bach, attending physician at Memorial Sloan-Kettering ­ ancer C

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WORKSHOP SUMMARY 11 25,000 Monthly Cost of Treatment 20,000 (U.S. dollars) 15,000 10,000 5,000 0 1960 1970 1980 1990 2000 2010 Year of FDA Approval FIGURE 3  Monthly and median costs of cancer drugs at the time of Food and Drug Administration approval, 1965–2008. Dots represent the cost of 1 month of cancer treatment for an individual who weighs 70 kilograms or has a body-surface area of 1.7 m2. The line indicates median drug prices over 5-year time intervals. NOTE: Prices are adjusted to 2007 U.S. dollars. SOURCES: Bach presentation (October 9, 2012) and Bach, 2009. From New England Journal of Medicine, P. B. Bach, Limits on Medicare’s ability to control rising spending on cancer drugs, Volume No. 360, Page Nos. 626–633. Copyright © (2009) Massachu- setts Medical Society. Reprinted with permission from Massachusetts Medical Society. Center. After the implementation of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA),3 the spending on Medicare Part B drugs dropped in 2005 (see Figure 4), but not as much as most people expected, in part because manufacturers responded by raising their unit prices, he said. Peppercorn suggested that the increasing drug prices may be in part due to the rise of innovative targeted treatments. Pharmaceutical companies may be pricing these therapies higher to recoup research and development costs, 3MMA changed the way physician-administered (Medicare Part B) drugs are reim- bursed. Many Medicare Part B drugs are used in oncology care. Prior to implementation, oncologists were reimbursed at a percentage of a drug’s average wholesale price (AWP). Now oncologists are reimbursed based on the drug’s average sales price (ASP) plus 6 percent and an administrative fee (Jacobson et al., 2006).

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64 DELIVERING AFFORDABLE CANCER CARE IN THE 21st CENTURY FIGURE 11  Dissemination of accountable care organizations (ACOs) in the United States. The public-sector ACOs include a few variations: Beacon Communities, the Medicare Physician Group Practice (PGP) Transition Demonstration, the Medicare Health Care Quality (MHCQ) Demonstration Programs, the Pioneer ACO Model, and the Medicare Shared Savings Program (MSSP). Beacon Communities aim to demonstrate how investments in health information technology and meaningful use of electronic medical records can promote patient-centered care. The Medicare PGP Transition Demonstration is evaluating how payment arrangements can help groups of physicians provide high-quality, coordinated care. The MHCQ Demonstration Pro- grams are designed to examine how changes to health care delivery and financing can improve the quality of care without increasing total Medicare program expenditures. The Pioneer ACO model is a CMS Innovation Center initiative designed to assess the impact of different payment initiatives for experienced ACOs. The Medicare Shared Savings Program is designed to reward ACOs that lower the growth in health care costs and meet performance metrics. SOURCE: McClellan presentation (October 8, 2012). IT development to help us collect, interpret, and act on data, and to focus on quality outcomes and identify high-risk patients,” he said, adding that they are currently considering hiring care coordinators and psychological counselors in this model practice. Incorporating these individuals will require an investment in resources, but he stressed that most physician practices cannot afford this investment and suggested that there needs to be an external mechanism to support these providers. McClellan noted that many medical homes found they were not able to pay their primary care providers more for delivering more coordinated care and better management of chronic disease using the traditional pri-

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WORKSHOP SUMMARY 65 mary care reimbursement system. Consequently, some have adopted an ACO method of payment, in which primary care physicians take on some accountability, not just for whether they meet all the criteria of a medical home, but whether they are actually lowering complication rates and cost trends for their patient population. McClellan added, “This is a new kind of risk to take on, one that takes some time and effort to build into, but it is happening.” These hybrid medical home-ACOs recognize that “you can’t get overall costs down, especially for conditions like cancer where the care predominantly involves specialists, without active involvement by specialists in the process,” McClellan said. So these medical home-ACO hybrids tend to rely on episode-based payments, he noted. Cost-Effectiveness Thresholds Other speakers suggested having cost-effective thresholds for medical interventions in oncology, akin to what is done in the national health care system offered by the United Kingdom (NHS, 2012). If interventions exceed cost-effectiveness thresholds (as measured by quality-adjusted life years), the National Health Service will generally not provide coverage for the interventions. “We have a whole literature on cost-effectiveness evalua- tion, much of it done in cancer, that puts a value on the various treatments that we do. We could set a national threshold and say we will only cover things that fall below that,” said Ramsey. Accountable Drugs and Devices Manufacturers of drugs, tests, and devices are increasingly being asked by insurers to be more accountable, with reimbursement rates being tied to the impact various tests and devices have on patient care. For example, instead of paying a set amount for a diagnostic test such as Oncotype DX,14 insurers could base the price on the value of avoiding unnecessary and costly chemotherapies, McClellan noted. Similarly, Betaseron is an expensive bio- logic drug for rheumatoid arthritis patients who are not responding to other treatments. In a new payment scheme devised by Health Alliance Medical 14A multigene expression test developed to predict the risk of recurrence for node- negative, estrogen-receptor-positive breast cancer. Oncotype DX may help identify women who are at such low risk of breast cancer recurrence that the risks of chemotherapy treatment would outweight the benefits of the treatment (IOM, 2012).

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66 DELIVERING AFFORDABLE CANCER CARE IN THE 21st CENTURY Plans and Bayer, the maker of Betaseron, the rebate for using Betaseron is tied to how often patients who are on it have complications requiring hospitalization for their rheumatoid arthritis, McClellan reported. “This is a way of shifting toward more accountability for results by manufacturers of the products,” he said. Competitive Bidding The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 enabled CMS to conduct a competitive acquisition program (CAP) to acquire drugs at lower costs for their beneficiaries. This program failed due to administrative difficulties, according to Bach, but could be modified so it is more effective. Such a program could be applied to the acquisition of the top 10 Medicare Part B drugs administered by physicians, most of which are used in the cancer setting. He also suggested putting any drugs beyond a certain price into such a program. Emanuel suggested expanding competitive bidding to drugs, imag- ing, and laboratory tests. He noted that the Affordable Care Act includes competitive bidding for durable medical equipment, such as prosthetics and orthotics. In the first year of its operation, prices for such commodi- ties decreased by 42 percent, he said, and the program is to be expanded throughout the country by 2016. WRAP-UP Many workshop participants stressed that all stakeholders are responsi- ble for the unsustainable rising costs of cancer care, which places affordable, high-quality cancer care in jeopardy. Tina Shih, director of the Program in the Economics of Cancer at the University of Chicago, emphasized, “Don’t think about the enemy as being out there. The take-home message from today’s meeting is that we are the ones creating the problem and we need to come together to solve it.” Peppercorn added, “The era of high-cost inter- ventions for marginal benefit clearly must end, particularly if we are going to have any resources left to provide high-value interventions to the broader population and to spend on further scientific discovery, not to mention the other important social goals.” Possible strategies for curbing the costs of cancer care include

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WORKSHOP SUMMARY 67 • providing financial incentives aligned with patient-centered, high-  quality, affordable, and coordinated care; • better means of assessing and paying for medical interventions; • greater use of and adherence to treatment guidelines; and • better informed and educated patients and providers, so that their  expectations are more realistic and cost conscious. Summing up the various alternative delivery and reimbursement schemes, McClellan said, “All these different kinds of reforms—medical homes, bundled payments, ACOs, and new payments for drugs—hopefully will align the different pieces of our provider payment models in a way that reinforces a common set of goals for patients. You should not view these as competing alternatives, but rather as pieces that are incrementally but fundamentally changing the way that we pay for care so payment is much better aligned with paying for value.” REFERENCES Abernethy, A. P., G. Raman, E. M. Balk, J. M. Hammond, L. A. Orlando, J. L. Wheeler, J. Lau, and D. C. McCrory. 2009. Systematic review: Reliability of compendia methods for off-label oncology indications. Annals of Internal Medicine 150(5):336-343. Abernethy, A. P., R. R. Coeytaux, K. Carson, D. McCrory, S. Y. Barbour, M. Gradison, R. J. Irvine, and J. L. Wheeler. 2010a. Report on the evidence regarding off-label indications for targeted therapies used in cancer treatment: Technology assessment report. Rockville, MD: Agency for Healthcare Research and Quality. Abernethy, A. P., L. M. Etheredge, P. A. Ganz, P. Wallace, R. R. German, C. Neti, P. B. Bach, and S. B. Murphy. 2010b. Rapid-learning system for cancer care. Journal of Clinical Oncology 28(27):4268-4274. ACS CAN (American Cancer Society Cancer Action Network). 2009. Cancer and Medicare: A chartbook. http://www.allhealth.org/briefingmaterials/CancerandMedicareChartbook FinalfulldocumentMarch11-1412.pdf (accessed January 8, 2013). AHRQ (Agency for Healthcare Research and Quality). 2011. What is the PCMH? http:// pcmh.ahrq.gov/portal/server.pt/community/pcmh__home/1483/what_is_pcmh_ (accessed January 23, 2013). American College of Surgeons. 2013. Rapid Quality Reporting System (RQRS). http://www. facs.org/cancer/ncdb/rqrs.html (accessed January 23, 2013). Anderson, G. F., and D. A. Squires. 2010. Measuring the U.S. health care system: A cross- national comparison. http://www.commonwealthfund.org/~/media/Files/Publications/ Issue%20Brief/2010/Jun/1412_Anderson_measuring_US_hlt_care_sys_intl_ib.pdf (accessed January 8, 2013).

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72 DELIVERING AFFORDABLE CANCER CARE IN THE 21st CENTURY Ramsey, S. D., and A. Schickedanz. 2010. How should we define value in cancer care? The Oncologist 15:s1. Ramsey, S. D., C. R. Fedorenko, K. S. Snell, A. C. Kirchhoff, W. Hollingworth, and D. K. Blough. Cancer diagnosis as a risk factor for personal bankruptcy. Journal of Clinical Oncology 29(Suppl):abstr 6007. Sanda, M. G., R. L. Dunn, J. Michalski, H. M. Sandler, L. Northouse, L. Hembroff, X. Lin, T. K. Greenfield, M. S. Litwin, C. S. Saigal, A. Mahadevan, E. Klein, A. Kibel, L. L. Pisters, D. Kuban, I. Kaplan, D. Wood, J. Ciezki, N. Shah, and J. T. Wei. 2008. Quality of life and satisfaction with outcome among prostate-cancer survivors. New England Journal of Medicine 358(12):1250-1261. Schnipper, L. E., T. J. Smith, D. Raghavan, D. W. Blayney, P. A. Ganz, T. M. Mulvey, and D. S. Wollins. 2012. American Society of Clinical Oncology identifies five key opportunities to improve care and reduce costs: The top five list for oncology. Journal of Clinical Oncology 30(14):1715-1724. SEER (Surveillance, Epidemiology and End Results). 2012. SEER stat fact sheets: All sites. http://seer.cancer.gov/statfacts/html/all.html (accessed December 16, 2012). Shankaran, V., S. Jolly, D. Blough, and S. D. Ramsey. 2012. Risk factors for financial hardship in patients receiving adjuvant chemotherapy for colon cancer: A population-based exploratory analysis. Journal of Clinical Oncology 30(14):1608-1614. Sheets, N. C., G. H. Goldin, A. Meyer, Y. Wu, Y. Chang, T. Stürmer, J. A. Holmes, B. B. Reeve, P. A. Godley, W. R. Carpenter, and R. C. Chen. 2012. Intensity-modulated radiation therapy, proton therapy, or conformal radiation therapy and morbidity and disease control in localized prostate cancer. Journal of the American Medical Association 307(15):1611-1620. Siegel, R., E. Ward, O. Brawley, and A. Jemal. 2011. Cancer statistics, 2011: The impact of eliminating socioeconomic and racial disparities on premature cancer deaths. CA: A Cancer Journal for Clinicians 61(4):212-236. Smith, B. D., G. L. Smith, A. Hurria, G. N. Hortobagyi, and T. A. Buchholz. 2009. Future of cancer incidence in the United States: Burdens upon an aging, changing nation. Journal of Clinical Oncology 27(17):2758-2765. Smith, G. L., Y. Xu, T. A. Buchholz, B. D. Smith, S. H. Giordano, B. G. Haffty, F. A. Vicini, J. R. White, D. W. Arthur, J. R. Harris, and Y. T. Shih. 2011. Brachytherapy for accelerated partial-breast irradiation: A rapidly emerging technology in breast cancer care. Journal of Clinical Oncology 29(2):157-165. Smith, T. J., and B. E. Hillner. 2011. Bending the cost curve in cancer care. New England Journal of Medicine 364(21):2060-2065. Smith, T. J., and D. L. Longo. 2012. Talking with patients about dying. New England Journal of Medicine 367(17):1651-1652. Smith, T. J., J. Khatcheressian, G. H. Lyman, H. Ozer, J. O. Armitage, L. Balducci, C. L. Bennett, S. B. Cantor, J. Crawford, S. J. Cross, G. Demetri, C. E. Desch, P. A. Pizzo, C. A. Schiffer, L. Schwartzberg, M. R. Somerfield, G. Somlo, J. C. Wade, J. L. Wade, R. J. Winn, A. J. Wozniak, and A. C. Wolff. 2006. 2006 update of recommendations for the use of white blood cell growth factors: An evidence-based clinical practice guideline. Journal of Clinical Oncology 24(19):187-205.

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