Accountability Measures Essential for Continued Delivery of Equitable High-Quality Cancer Care

As the Centers for Medicare & Medicaid Services(CMS) moves toward a payment system linked toquality performance, it is important that the oncologycommunity participates in the ongoing debateover how to define best quality care and how todeliver it. In order to shed light on this importantissue, Cancer Care & Economics (CC&E) recentlyspoke with Patricia Ganz, MD, professor of healthservices and medicine, UCLA School of PublicHealth. Dr. Ganz is a member of the board of theAmerican Society of Clinical Oncology (ASCO) andco-chair of the Cancer Quality Alliance, a collaborationbetween ASCO and the National Coaltion forCancer Survivorship (NCCS). The opinions expressedin the interview are Dr. Ganz's own and not necessarilythose of ASCO.

CC&E: Please describe your work withthe Cancer Quality Alliance.

DR. GANZ: I am co-chairing the CancerQuality Alliance with Ellen Stovall,from the National Coalition for CancerSurvivorship, and I am representingASCO in doing that. The Alliance's prioritiesare to develop a template of qualityoncology care and to adopt and testquality measures. Among other things,we're also focusing on novel approachesto coordinate the multidisciplinary aspectsof cancer care.

CC&E: How does the Alliance feelabout the CMS 2006 DemonstrationProject and the pay-for-performance(P4P) initiative?

DR. GANZ: We view the current DemonstrationProject as very favorable. Thepay-per-performance initiative, while itmay seem punitive to some, has greatpower to enhance dissemination of thetreatments that we know are effectivewithin the clinical setting.

Most of the improvements we've seenin cancer survival have been through theapplication of evidence-proven therapies.But we do not have administrative orclaims data that link us to the clinicalevidence. Current data do not have thenuanced information about stage andother fine details that gauge whether thetherapy being applied was the best option.With the CMS DemonstrationProject, there is an opportunity to harvestthat important information fromphysicians in real-time clinical values,which will help us transition to a systemthat rewards performance.

CC&E: How can CMS accuratelyevaluate performance in the complex andconstantly evolving world of cancertreatment?

DR. GANZ: Unlike other diseases, incancer we have the challenge of 100different disease entities. However, wealso have a large amount of randomizedcontrol trial evidence. In fact, almost allcancer therapy is derived from trial evidence.For the most common diseases,breast, colon, prostate, and lung, we havemany studies that give us direction as towhat the appropriate care might be.

There are guidelines data that summarize that evidence and give recommendationsfor specific treatments. So, evengiven the complexity of cancer care, it isquite reasonable to be able to evaluatewhether a patient has received appropriatetreatment based on our growing bodyof clinical trial evidence.

CC&E: Adult clinical trial participationis still dismally low. Since most cancercare is delivered in the communitysetting, do you see a relationship betweenthat and the low participation in clinicaltrials?

DR. GANZ: Yes, I think that is exactlythe case. Unlike tertiary centers, communitypractices don't have the built-ininfrastructure and nursing staff to supportclinical trials. The extra time andexpense it takes for a community practitionerto enroll patients in clinical trialsoften proves untenable. It's definitelysomething that needs a frank appraisal ifwe seriously want to address the pooraccrual rate of adult patients on cancerclinical trials.

CC&E: Do you feel that a universalHealth Information Technology systemis an important agenda for the oncologycommunity?

DR. GANZ: Yes, I do. Electronic systemscan help cancer care be more costeffectiveand less prone to errors. I workin an academic setting where I have accessto electronic records. I can easilypull up any laboratory tests or radiologystudies I need while treating a patient.

Typically, a paper chart system is muchmore cumbersome; it allows moreopportunity to miss abnormal test results,and, in effect, it creates wastefulduplication. E-records also facilitate a synergisticcommunication in which all physiciansinvolved in the care of a patienthave instant access to the same data.Obviously, that makes for safer, better,and more cost-effective care.

CC&E: Does our reimbursement systemcreate incentives for abuse?

DR. GANZ: I come from an academicsituation where I don't have any financialincentives to order tests or prescribetherapeutics. But that's not the case inthe real world where we have seen a proliferation of MRI, PET, and CT scanswithout sufficient evidence for their benefitin terms of patient monitoring orfollow-up.

Some oncologists may try to make upfor the reimbursement shortfall in today'snew tighter payment structure by billingfor excessive procedures and tests. It's ashort-sighted solution that will ultimatelybackfire.

With our aging population, we are goingto experience an explosion of cancer, simplyby that demographic imperative,and there is going to be less and lessmoney available to treat people effectively.A conscientious approach to thisis to acknowledge that the coffers are notlimitless and make the necessary adjustmentsin practice methodologies, ratherthan have stringent guidelines imposedon us by third parties.

CC&E: Any closing thoughts?

DR. GANZ: We are currently seeingsubstantial results from new cancer therapies,which are the payoff of the last 15 to20 years of hard clinical research. That'sexciting. But I fear that if our finite medicalresources are not used judiciously,based on best practice evidence, we willultimately strain the nation's health carebudget to the point where the delivery ofequitable, high-quality cancer care mightbe threatened.

The move toward evidence-based care,accountability, and performance incentivesis a positive step that will ultimatelysave money and produce better outcomes.I believe we are at a great medicalcrossroad in terms of our growing understandingof cancer biology and genetics.It is just a matter of getting systems inplace that allow us to deliver cost-effective,high-quality cancer care within thedynamics of today's looming fiscalcrunch.