Practical Radiation Oncology (2015) 5, 274-276
www.practicalradonc.org
Commentary
The dangers of incorporating reimbursement data into clinical decision making Sewit Teckie MD, Louis Potters MD ⁎ Department of Radiation Medicine, North Shore-LIJ Cancer Institute, Lake Success, New York Hofstra North Shore-LIJ School of Medicine, Hempstead, New York Received 30 December 2014; accepted 6 January 2015
Value is a concept much discussed in recent health care literature but often misunderstood. It has been defined as outcome divided by cost or quality divided by cost, and its application is limited secondary to an inability to measure its components, especially cost. 1 Cost as part of the value equation refers to the true costs of a patient’s treatment for any one condition, including all of the multidisciplinary components of care. Unfortunately, cost accounting is not straightforward. Time-driven activity-based costing 2 requires that the clinical condition be carefully mapped out on the basis of its granular components, assessing the time and the cost of each part of the clinical process. This exercise is time and resource intensive and to date has had limited real-world experience. One early attempt at time-driven activity-based costing resulted in the recent implementation of a bundled payment for head and neck cancer treatment at MD Anderson Cancer Center in Houston, Texas. 3 Equally problematic to cost accounting is the lack of uniformity in assessing outcomes, including clinical and toxicity endpoints. So to be clear, we have not yet established value for most cancer patients, and furthermore, we have not properly assessed the true cost of radiation therapy. Given the inherent difficulties in measuring value, payers have decided that cutting costs in the denominator (by reducing reimbursements and coverage) is a surrogate for increasing value. They are See Related Article on p 267. Conflicts of interest: None. DOI of original article: http://dx.doi.org/10.1016/j.prro.2014.10.014. ⁎ Corresponding author. Department of Radiation Medicine, 450 Lakeville Road, Lake Success, NY 11042. E-mail address: [email protected] (L. Potters).
manipulating one component of the equation to change the ratio. What they have tried to frame as value for radiation therapy is in fact an attempt to set valuation, which in simple terms represents a process of determining financial worth, or “bang for your buck.” Valuation is agnostic of outcomes and the patient; it is focused on the bottom line. In this context, the article by Gill et al 4 is thoughtprovoking in that it shows that radiation oncologists may misguidedly (under the ruse of value) incorporate reimbursement information (as a proxy for cost) into treatment decisions. In the study, the authors provided physicians with reimbursement data and limited clinic resources to observe changes in self-reported patient care behaviors. Specifically, 43 radiation oncologists completed electronic surveys about 9 clinical scenarios, each with 4 treatment choices based on their institutional clinical pathways. Physicians were asked to select their preferred treatment in each scenario (module 1). The authors then changed the circumstances of the hypothetical clinic and asked respondents to answer the surveys with the new information in mind. In module 2, physicians were operating in a bundled-payment environment, and in module 3, both payments and clinical resources (eg, staff and machine time) were limited. Notably, module 3 presented physicians with the “cost” of each treatment option listed; in reality, this “cost” was the reimbursement amount. Overall, the authors found that radiation oncologists chose more of the lower-reimbursing treatment options when presented with both bundled-payment and restricted resources. Unfortunately, respondents changed their treatment decisions armed only with reimbursement data and not the actual costs of each treatment. Contrary to what is widely believed, there is often no direct relationship between the
http://dx.doi.org/10.1016/j.prro.2015.01.002 1879-8500/© 2015 American Society for Radiation Oncology. Published by Elsevier Inc. All rights reserved.
Practical Radiation Oncology: July-August 2015
cost of care and reimbursement. 1 Physicians who answered these surveys were presumably left to equate reimbursement with the costs of each treatment to the department, practice, or health care system at large. We believe this manipulation is a dangerous precedent for radiation oncology and cancer patients. Well-intentioned physicians armed with reimbursement data may be led to believe their actions are cost-effective without knowing the whole picture. At its core, this study is based on the notion that radiation oncology is overpaid and that by changing resource allocations (as a reflection of reimbursement), we can save the “system” money without impacting patient care. 5 This thinking is the same process by which third-party radiation oncology business managers (ROBMs) operate to save money for insurance companies by limiting intensity modulated radiation therapy (IMRT), radiosurgery, and similar treatments. And yet, because of the disconnect between reimbursement and cost, the manipulation of clinical decisions that influence the physician to choose a lower-reimbursing option may not always translate into a cost savings. Paradoxically, the lower-reimbursing treatment option may in fact use more clinical resources. Consider, for example, the case of single-fraction stereotactic radiosurgery (SRS) for brain metastases. Curiously, more physicians in this study switched to using single-fraction SRS for a patient with 4 brain metastases when resources and payments were restricted. But what about physician supervision time, physics, and the longer machine time needed to treat this patient? In a cost-accounting analysis, the total manpower and time cost of these resources may equal, or even exceed, that of 10-fraction whole brain radiation therapy. Putting aside the dangers of altering clinical decisions based on reimbursement information, there are notable findings in the behavior of the physicians who took part in this survey that may help shape future discussion about physician attitudes about payment reform. First and most important, the selection of treatment options was based on a foundation of institution-developed care pathways. Presumably, these pathways, either evidence based, consensus driven, or both, were indistinguishable in terms of perceived outcome for each of the 9 case scenarios. This fact is vital because the survey never asked participants to potentially compromise care. Therefore, any rearrangement of the use of these pathways, regardless of the reason, can be considered clinically meaningless in terms of overall clinical outcome. Without outcome data for each pathway, the interchangeability of treatment options is confounded by the physician’s beliefs about what treatments are best. Most respondents to this survey overwhelmingly chose 1 or 2 of the 4 treatment options in each scenario, presumably because they believed the selected treatment to be the best. In theory and in practice, 6,7 value is driven by the use of standardized pathways that reduce extreme variability of
Reimbursement and clinical decision making
275
care. Not only are variations in care monetarily costly, they also dilute the opportunity and power to assess outcomes. As we outlined above, outcome information is crucial for determining value. Furthermore, variations in care increase safety risks and accidents. Given the power of standardized pathways, outcomes measured within these pathways may provide better insight into the effect of patient and physician variables on relevant endpoints. When reading the study by Gill et al 4 in the context of value, it becomes alarmingly clear that we do not know the patient outcomes that result from physicians changing treatment decisions based on reimbursement alone. If everyone reduced the use of IMRT for patients with lung cancer, would patients be better off or worse off? What about prostate cancer: would we see more rectal toxicity if we used less IMRT? Is increasing the use of SRS always the best option for patients with limited brain metastases? Without a foundation of pathway-based treatment, the current ad hoc nature of care precludes proper riskadjusted outcomes measurement. Recent data show that ad hoc care and the lack of compliance associated with standardization are associated with treatment failure and disease mortality. 8 Thus, standardization and compliance become the core for assessing outcomes. Medicine in general and radiation oncology in particular have a long way to go in developing processes to build and implement pathways that allow for evidence, consensus, and personalized care. So, is there a solution for the conundrum of value and real-life day-to-day patient care? As many have said before, it may lie in restructuring reimbursements. There is no question that current reimbursement is misaligned with cost, and the current reimbursement scheme using relative value is flawed. 9 It is particularly troublesome that this broken reimbursement system has become the engine for changes all across health care, including ROBM’s care management programs, the study by Gill et al, 4 and even for measuring physician productivity. But most troubling is that this type of exercise potentially limits the use of technologies such as IMRT, stereotactic body radiation therapy, and protons, not because of efficacy, but because of their current (higher) reimbursement, which has little relationship to cost. In the context of emerging research on how to influence human behavior, we are heartened by the fact that the study by Gill et al 4 shows that physician behavior is malleable. If given the correct evidence base, physicians will make treatment decisions that optimize patient outcomes. As we have learned from news reports related to the recent release of Medicare physician payment data, financial incentives associated with high reimbursement do influence physician decisions regarding patient care. 10 Similarly, this study demonstrates that the creation of an environment that limits care can be equally successful in restricting physician behavior. Unfortunately, influencing decisions using either high or low
276
S. Teckie and L. Potters
reimbursement is not the best model to affect this change, nor is it in the patient’s best interest. As such, this study must not be construed as a validation for ROBM management restrictions on technology. In the end, if we make honest decisions about patient care that are associated with value, we will not be manipulated by the financial factors. As we set about building the framework for understanding the valuation of health care, where real outcomes are a reflection of cost, we need to be careful that the patient, like the proverbial baby, is not thrown out with the bathwater.
Practical Radiation Oncology: July-August 2015
4.
5.
6.
7.
References 8. 1. Teckie S, McCloskey SA, Steinberg ML. Value: A framework for radiation oncology. J Clin Oncol. 2014;32(26):2864-2870. 2. Kaplan RS, Porter ME. How to solve the cost crisis in health care. Harv Bus Rev. 2011;89(9):46-52. 54, 56-61 passim. Available at: http://www. ncbi.nlm.nih.gov/pubmed/21939127. Accessed December 11, 2014. 3. Mathews AW. UnitedHealthcare tests a flat rate for cancer treatment. The Wall Street Journal. December 15, 2014. Available at: http://
9. 10.
www.wsj.com/articles/unitedhealthcare-tests-a-flat-rate-for-cancertreatment-1418619661. Accessed December 16, 2014. Gill BS, Beriwal S, Rajagopalan MS, Wang H, Hodges K, Greenberger JS. Quantitative evaluation of radiation oncologists’ adaptability to lower reimbursing treatment programs [e-pub ahead of print]. Pract Radiat Oncol. http://dx.doi.org/10.1016/j.prro.2014. 10.014, accessed December 8, 2014. Wallner PE, Steinberg ML, Konski AA. Controversies in the adoption of new healthcare technologies. Front Radiat Ther Oncol. 2011;43:60-78. Potters L, Raince J, Chou H, et al. Development, implementation, and compliance of treatment pathways in radiation medicine. Front Oncol. 2013;3:105. Kim CS, Hayman JA, Billi JE, Lash K, Lawrence TS. The application of lean thinking to the care of patients with bone and brain metastasis with radiation therapy. J Oncol Pract. 2007;3(4): 189-193. Ohri N, Shen X, Dicker AP, Doyle LA, Harrison AS, Showalter TN. Radiotherapy protocol deviations and clinical outcomes: A metaanalysis of cooperative group clinical trials. J Natl Cancer Inst. 2013;105(6):387-393. Stecker EC, Schroeder SA. Adding value to relative-value units. N Engl J Med. 2013;369(23):2176-2179. Davidson SM. Open questions concerning influences on clinical decision making. J Ambul Care Manage. 2013;36(2):88-107.
www.practicalradonc.org
Commentary
The dangers of incorporating reimbursement data into clinical decision making Sewit Teckie MD, Louis Potters MD ⁎ Department of Radiation Medicine, North Shore-LIJ Cancer Institute, Lake Success, New York Hofstra North Shore-LIJ School of Medicine, Hempstead, New York Received 30 December 2014; accepted 6 January 2015
Value is a concept much discussed in recent health care literature but often misunderstood. It has been defined as outcome divided by cost or quality divided by cost, and its application is limited secondary to an inability to measure its components, especially cost. 1 Cost as part of the value equation refers to the true costs of a patient’s treatment for any one condition, including all of the multidisciplinary components of care. Unfortunately, cost accounting is not straightforward. Time-driven activity-based costing 2 requires that the clinical condition be carefully mapped out on the basis of its granular components, assessing the time and the cost of each part of the clinical process. This exercise is time and resource intensive and to date has had limited real-world experience. One early attempt at time-driven activity-based costing resulted in the recent implementation of a bundled payment for head and neck cancer treatment at MD Anderson Cancer Center in Houston, Texas. 3 Equally problematic to cost accounting is the lack of uniformity in assessing outcomes, including clinical and toxicity endpoints. So to be clear, we have not yet established value for most cancer patients, and furthermore, we have not properly assessed the true cost of radiation therapy. Given the inherent difficulties in measuring value, payers have decided that cutting costs in the denominator (by reducing reimbursements and coverage) is a surrogate for increasing value. They are See Related Article on p 267. Conflicts of interest: None. DOI of original article: http://dx.doi.org/10.1016/j.prro.2014.10.014. ⁎ Corresponding author. Department of Radiation Medicine, 450 Lakeville Road, Lake Success, NY 11042. E-mail address: [email protected] (L. Potters).
manipulating one component of the equation to change the ratio. What they have tried to frame as value for radiation therapy is in fact an attempt to set valuation, which in simple terms represents a process of determining financial worth, or “bang for your buck.” Valuation is agnostic of outcomes and the patient; it is focused on the bottom line. In this context, the article by Gill et al 4 is thoughtprovoking in that it shows that radiation oncologists may misguidedly (under the ruse of value) incorporate reimbursement information (as a proxy for cost) into treatment decisions. In the study, the authors provided physicians with reimbursement data and limited clinic resources to observe changes in self-reported patient care behaviors. Specifically, 43 radiation oncologists completed electronic surveys about 9 clinical scenarios, each with 4 treatment choices based on their institutional clinical pathways. Physicians were asked to select their preferred treatment in each scenario (module 1). The authors then changed the circumstances of the hypothetical clinic and asked respondents to answer the surveys with the new information in mind. In module 2, physicians were operating in a bundled-payment environment, and in module 3, both payments and clinical resources (eg, staff and machine time) were limited. Notably, module 3 presented physicians with the “cost” of each treatment option listed; in reality, this “cost” was the reimbursement amount. Overall, the authors found that radiation oncologists chose more of the lower-reimbursing treatment options when presented with both bundled-payment and restricted resources. Unfortunately, respondents changed their treatment decisions armed only with reimbursement data and not the actual costs of each treatment. Contrary to what is widely believed, there is often no direct relationship between the
http://dx.doi.org/10.1016/j.prro.2015.01.002 1879-8500/© 2015 American Society for Radiation Oncology. Published by Elsevier Inc. All rights reserved.
Practical Radiation Oncology: July-August 2015
cost of care and reimbursement. 1 Physicians who answered these surveys were presumably left to equate reimbursement with the costs of each treatment to the department, practice, or health care system at large. We believe this manipulation is a dangerous precedent for radiation oncology and cancer patients. Well-intentioned physicians armed with reimbursement data may be led to believe their actions are cost-effective without knowing the whole picture. At its core, this study is based on the notion that radiation oncology is overpaid and that by changing resource allocations (as a reflection of reimbursement), we can save the “system” money without impacting patient care. 5 This thinking is the same process by which third-party radiation oncology business managers (ROBMs) operate to save money for insurance companies by limiting intensity modulated radiation therapy (IMRT), radiosurgery, and similar treatments. And yet, because of the disconnect between reimbursement and cost, the manipulation of clinical decisions that influence the physician to choose a lower-reimbursing option may not always translate into a cost savings. Paradoxically, the lower-reimbursing treatment option may in fact use more clinical resources. Consider, for example, the case of single-fraction stereotactic radiosurgery (SRS) for brain metastases. Curiously, more physicians in this study switched to using single-fraction SRS for a patient with 4 brain metastases when resources and payments were restricted. But what about physician supervision time, physics, and the longer machine time needed to treat this patient? In a cost-accounting analysis, the total manpower and time cost of these resources may equal, or even exceed, that of 10-fraction whole brain radiation therapy. Putting aside the dangers of altering clinical decisions based on reimbursement information, there are notable findings in the behavior of the physicians who took part in this survey that may help shape future discussion about physician attitudes about payment reform. First and most important, the selection of treatment options was based on a foundation of institution-developed care pathways. Presumably, these pathways, either evidence based, consensus driven, or both, were indistinguishable in terms of perceived outcome for each of the 9 case scenarios. This fact is vital because the survey never asked participants to potentially compromise care. Therefore, any rearrangement of the use of these pathways, regardless of the reason, can be considered clinically meaningless in terms of overall clinical outcome. Without outcome data for each pathway, the interchangeability of treatment options is confounded by the physician’s beliefs about what treatments are best. Most respondents to this survey overwhelmingly chose 1 or 2 of the 4 treatment options in each scenario, presumably because they believed the selected treatment to be the best. In theory and in practice, 6,7 value is driven by the use of standardized pathways that reduce extreme variability of
Reimbursement and clinical decision making
275
care. Not only are variations in care monetarily costly, they also dilute the opportunity and power to assess outcomes. As we outlined above, outcome information is crucial for determining value. Furthermore, variations in care increase safety risks and accidents. Given the power of standardized pathways, outcomes measured within these pathways may provide better insight into the effect of patient and physician variables on relevant endpoints. When reading the study by Gill et al 4 in the context of value, it becomes alarmingly clear that we do not know the patient outcomes that result from physicians changing treatment decisions based on reimbursement alone. If everyone reduced the use of IMRT for patients with lung cancer, would patients be better off or worse off? What about prostate cancer: would we see more rectal toxicity if we used less IMRT? Is increasing the use of SRS always the best option for patients with limited brain metastases? Without a foundation of pathway-based treatment, the current ad hoc nature of care precludes proper riskadjusted outcomes measurement. Recent data show that ad hoc care and the lack of compliance associated with standardization are associated with treatment failure and disease mortality. 8 Thus, standardization and compliance become the core for assessing outcomes. Medicine in general and radiation oncology in particular have a long way to go in developing processes to build and implement pathways that allow for evidence, consensus, and personalized care. So, is there a solution for the conundrum of value and real-life day-to-day patient care? As many have said before, it may lie in restructuring reimbursements. There is no question that current reimbursement is misaligned with cost, and the current reimbursement scheme using relative value is flawed. 9 It is particularly troublesome that this broken reimbursement system has become the engine for changes all across health care, including ROBM’s care management programs, the study by Gill et al, 4 and even for measuring physician productivity. But most troubling is that this type of exercise potentially limits the use of technologies such as IMRT, stereotactic body radiation therapy, and protons, not because of efficacy, but because of their current (higher) reimbursement, which has little relationship to cost. In the context of emerging research on how to influence human behavior, we are heartened by the fact that the study by Gill et al 4 shows that physician behavior is malleable. If given the correct evidence base, physicians will make treatment decisions that optimize patient outcomes. As we have learned from news reports related to the recent release of Medicare physician payment data, financial incentives associated with high reimbursement do influence physician decisions regarding patient care. 10 Similarly, this study demonstrates that the creation of an environment that limits care can be equally successful in restricting physician behavior. Unfortunately, influencing decisions using either high or low
276
S. Teckie and L. Potters
reimbursement is not the best model to affect this change, nor is it in the patient’s best interest. As such, this study must not be construed as a validation for ROBM management restrictions on technology. In the end, if we make honest decisions about patient care that are associated with value, we will not be manipulated by the financial factors. As we set about building the framework for understanding the valuation of health care, where real outcomes are a reflection of cost, we need to be careful that the patient, like the proverbial baby, is not thrown out with the bathwater.
Practical Radiation Oncology: July-August 2015
4.
5.
6.
7.
References 8. 1. Teckie S, McCloskey SA, Steinberg ML. Value: A framework for radiation oncology. J Clin Oncol. 2014;32(26):2864-2870. 2. Kaplan RS, Porter ME. How to solve the cost crisis in health care. Harv Bus Rev. 2011;89(9):46-52. 54, 56-61 passim. Available at: http://www. ncbi.nlm.nih.gov/pubmed/21939127. Accessed December 11, 2014. 3. Mathews AW. UnitedHealthcare tests a flat rate for cancer treatment. The Wall Street Journal. December 15, 2014. Available at: http://
9. 10.
www.wsj.com/articles/unitedhealthcare-tests-a-flat-rate-for-cancertreatment-1418619661. Accessed December 16, 2014. Gill BS, Beriwal S, Rajagopalan MS, Wang H, Hodges K, Greenberger JS. Quantitative evaluation of radiation oncologists’ adaptability to lower reimbursing treatment programs [e-pub ahead of print]. Pract Radiat Oncol. http://dx.doi.org/10.1016/j.prro.2014. 10.014, accessed December 8, 2014. Wallner PE, Steinberg ML, Konski AA. Controversies in the adoption of new healthcare technologies. Front Radiat Ther Oncol. 2011;43:60-78. Potters L, Raince J, Chou H, et al. Development, implementation, and compliance of treatment pathways in radiation medicine. Front Oncol. 2013;3:105. Kim CS, Hayman JA, Billi JE, Lash K, Lawrence TS. The application of lean thinking to the care of patients with bone and brain metastasis with radiation therapy. J Oncol Pract. 2007;3(4): 189-193. Ohri N, Shen X, Dicker AP, Doyle LA, Harrison AS, Showalter TN. Radiotherapy protocol deviations and clinical outcomes: A metaanalysis of cooperative group clinical trials. J Natl Cancer Inst. 2013;105(6):387-393. Stecker EC, Schroeder SA. Adding value to relative-value units. N Engl J Med. 2013;369(23):2176-2179. Davidson SM. Open questions concerning influences on clinical decision making. J Ambul Care Manage. 2013;36(2):88-107.
