Letters to the Editor

Reply to A. Small et al To the Editor: Small et al1 call for careful measurement of the effects of payment changes on the quality of cancer care. One cannot disagree with this statement, but it is worth noting that it is challenging to find a study measuring a group of medical oncologists as carefully as was done in our study.2 The fee-forservice payment system is assumed to provide quality care, but supporting documentation for this assumption is scarce. Further, no studies have examined changes in quality as community practices are acquired by hospitals and then converted to fee schedules that are multiples of the previous community rates. We did have concerns about quality of care, and the measures allowed timely monitoring. Even though many of the quality measures require additional time and observations for statistical analysis, the early results allowed the groups to compare variances and learn from best practices. The critical point is that these measures were planned prospectively as a check and balance against underuse. Although we agree that hospitalizations are infrequent quality failures, the strength of the difference (P ⬍ .001) confirms how much impact this study had improving care. The lung cancer survival rates were also statistically confirmed to be equivalent to those of the fee-for-service cohort. Small and Brammer’s concern about a measure to detect underuse of appropriate, high-cost therapies is perplexing. Our study used chemotherapy drug costs, the highest cost therapy in cancer, as a primary end point and demonstrated an increased spend in the observation group. This single observation requires confirmation. The savings in our study were large, and we have already started a confirming study using other medical oncology groups. We agree that the study raises new questions about the influence of drug therapy on overall costs of care. We did not prove a correlation between drug spend and overall cost of care as suggested by Small et al; the two measures were independent. Similarly, the study did not assess the strength of buy-and-bill incentives, and it is erroneous to assume that those incentives are weak based on our data.

The five medical groups were chosen because of their large size, their clinical and business leadership, and their willingness to participate in this trial. Our statistical model did show that these groups were more cost effective than their peers in the preobservation period. The multiple regression model factored this advantage as a variable in the analysis. Other characteristics that may influence the ability to reduce costs will require further study. We welcome other studies of payment changes for cancer therapy. We hope that our study is the first of many. It is essential that society uses evidence rather than conventional wisdom to provide essential cancer therapy at an affordable cost. Lee N. Newcomer, Sheila A. Donelan, and Monica Perkins UnitedHealthcare, Minnetonka, MN Bruce Gould Northwest Georgia Oncology Centers, Marietta, GA Ray D. Page Center for Blood and Cancer Disorders, Fort Worth, TX Authors’ Disclosures of Potential Conflicts of Interest Disclosures provided by the authors are available with this article at jop.ascopubs.org.

Author Contributions Conception and design: All authors Collection and assembly of data: All authors Data analysis and interpretation: All authors Manuscript writing: All authors Final approval of manuscript: All authors Corresponding author: Lee N. Newcomer, MD, UnitedHealthcare, 9700 Health Care Lane, Mail Route MN017-W700, Minnetonka, MN 55343; e-mail: [email protected].

DOI: 10.1200/JOP.2014.002071; published online ahead of print at jop.ascopubs.org on December 16, 2014.

References 1. Small A, Brammer M: In response to L.N. Newcomer et al. J Oncol Pract 11:161, 2015

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2. Newcomer LN, Gould B, Page RD, et al: Changing physician incentives for affordable, quality cancer care: Results of an episode payment model. J Oncol Pract 10:322-326, 2014

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AUTHORS’ DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST Reply to A. Small et al The following represents disclosure information provided by authors of this manuscript. All relationships are considered compensated. Relationships are self-held unless noted. I ⫽ Immediate Family Member, Inst ⫽ My Institution. Relationships may not relate to the subject matter of this manuscript. For more information about ASCO’s conflict of interest policy, please refer to www.asco.org/rwc or jop.ascopubs.org/site/misc/ifc.xhtml. Lee N. Newcomer Employment: UnitedHealth Group Stock or Other Ownership: UnitedHealth Group, UnitedHealth Group

Sheila A. Donelan Employment: UnitedHealthcare Stock or Other Ownership: United Health Group Monica Perkins Employment: UnitedHealthcare Stock or Other Ownership: UnitedHealth Group

Bruce Gould Travel, Accommodations, Expenses: UnitedHealthcare Ray D. Page Stock or Other Ownership: Oncology Metrics Consulting or Advisory Role: International Oncology Network, via oncology Speakers’ Bureau: Biodesix, Celgene Research Funding: Gilead Sciences, Celgene, Bristol-Myers Squibb, Genentech/Roche, Pfizer Travel, Accommodations, Expenses: raintree

Copyright © 2014 by American Society of Clinical Oncology

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