As a primary care physician and cancer survivor, I’ve seen and experienced the physical and emotional toll the disease takes on patients and caregivers. Fortunately, great progress has been made on the clinical front, and cancer death rates are declining; yet, the financial toll of this disease keeps growing.
Cancer care costs have risen from $57 billion in 2001 to over $200 billion today, placing an increasingly unsustainable burden on patients, families, employers, and payers. While patients live longer, they are increasingly more likely to deplete their life savings or declare bankruptcy, or are forced to make hard choices between essentials like food and medicine. How can we reduce this spend while still advancing toward a future in which cancer deaths are reduced, outcomes improve, and quality of life during treatment and survivorship is enhanced?
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Historically, the issue that has gotten the most attention has been the high cost of cancer drugs. Cancer drugs account for 50% to 60% of total cancer spend, and the average price of new cancer drugs doubled between 2009 and 2019. The stratospheric costs of some targeted therapies can force patients, providers, and plans to make difficult choices they shouldn’t have to make.
Drugs, however, are not the only significant driver of rising cancer care costs. Avoidable emergency department (ED) visits and hospitalizations present a huge opportunity for cost reductions that should be explored.
One approach that can stem the rates of hospitalizations and emergency department visits involves a proactive outreach to patients to assess symptoms early and keep patients well and functioning in their homes and communities. But proactive outreach involves tools and techniques that are not always in the wheelhouse of physician offices today – either due to operational complexity or the upfront costs involved. How can we bring these types of solutions to scale?
Avoidable ED visits and hospitalizations
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Neither cancer nor its treatments are easy to bear. The physical difficulties of cancer care and the potent therapies used in treatment often lead to side-effects and symptoms, including pain, fever, nausea, and vomiting, that may warrant emergent care. Cancer patients may also have other comorbid medical conditions that complicate their cancer treatment. For example, for diabetes patients, the steroids used in certain cancer therapies can exacerbate their diabetes, sometimes to the point of diabetic ketoacidosis, a life-threatening medical condition.
Although ED visits and hospitalizations can be appropriate and necessary, their utilization rates have risen significantly over the past decade. Between 2012 and 2019, cancer-related ED visits increased by 67.1%. Of those cancer patients that visited the ED, 60% experienced an unplanned hospitalization, nearly four times the rate of the general population. The average cost of ED visits has also risen, from $1,854 to $2,568, between 2012 and 2019.
Beyond costs, there are other reasons why ED visits and hospitalizations can have a negative impact on patients with cancer. Waiting to see a doctor in a crowded ED can be a physically and emotionally taxing experience. An unplanned hospital stay can interfere with treatment by delaying appointments, follow-up visits, tests, and scans. Both EDs and hospitalizations can also be dangerous for immunosuppressed patients, putting them at risk of infections.
Optimistically, there is ample opportunity to reduce unnecessary utilization. Over half (51.6%) of ED visits by patients with cancer are considered avoidable, and 30.2% of preventable ED visits also result in (similarly preventable) hospitalizations. How can we meet the needs of cancer patients preemptively to help them avoid those unnecessary trips to the ED or hospital?
The role of cancer care navigation in reducing acute care costs
One powerful solution lies in care navigation. Numerous academic studies have shown that effective care navigation programs can reduce ED visits and hospitalizations for cancer patients. By leveraging a more hands-on understanding of a patient’s health status, social challenges, and treatment path, such navigation services have been shown to improve patient care coordination, symptom management, treatment adherence, sense of support, and ultimately, reduce cost.
Cancer care navigators are either clinical or non-clinical staff whose primary role is to remove barriers to care by facilitating access to appointments, enhancing coordination between oncologists, specialists, and primary care physicians, and arranging for social services such as transportation, nutritious food, and stable housing when necessary. They also regularly check-in with patients during treatment, monitor their symptoms, and respond proactively to care needs before they intensify. Those efforts are very effective at supporting clinical care teams, specifically mitigating the need for emergent care or hospitalization. In fact, in one study, navigation was shown to reduce both ED visits and hospitalizations by 25% among cancer patients.
If such programs are so powerful, then why haven’t they been implemented more broadly? Scaling cancer care navigation is challenging because the personal and social barriers to care come in many forms and can change over time. In order to be effective, programs must pair high-touch human engagement with the robust technology and data needed to scale.
Access to the right technology and analytical support can extend the reach of care navigation teams, such that even small teams can be robust enough to assess the needs of patients across a large population, and flag those in need of more individualized support. Tech-enabled screenings and assessments can hone in on those needs, and guide care teams in providing appropriate interventions and services. Intelligent technology can keep all members of the patient’s care team informed, notify them when actions or interventions are required, help coordinate care, and close the loop on referrals.
In this way, care teams can address patients’ needs proactively to avoid unnecessary hospitalizations. When programs are data-based and tech-enabled, it becomes possible to deliver such whole-person care on an individual basis at scale without adding to the administrative burden of care teams.
We are seeing the impact of navigation on lives, workloads, and cancer care costs. One of our studies showed that care navigation reduced the total cost of care for one Medicare Advantage population by $429 per member per month, with 58% of that reduction attributable to reductions in inpatient spend. Ultimately, we must scale those cost-saving benefits over larger populations of cancer patients while improving the outcomes and experience of cancer care.
The U.S. spends more on cancer care than any other major economically advanced nation, without achieving lower cancer mortality rates. Given the percentage of that spend devoted to cancer drugs, it is no surprise that efforts to reduce overall cancer care costs focus almost exclusively on that front.
Yet, a significant amount of money is also spent on avoidable acute care, especially at EDs and hospitals. Payers and at-risk providers that are considering care management programs to reduce avoidable ED visits and hospitalizations for their general patient population should also consider the significant potential for savings and performance improvement in programs designed specifically for their cancer populations
Implementing cancer care navigation programs that improve access, adherence, coordination, proactive symptom management, and goal concordant care not only reduces acute care utilization but also improves patient outcomes and experience, measures that are increasingly important in value-based programs.
We know that patients with cancer respond best to a whole-person approach to care. It’s time to implement a similarly holistic strategy to tackle cancer’s rising costs.
Photo: JPLDesigns, Getty Images
Dr. Brad Diephuis, MD, MBA, is a primary care physician and Chief Business Officer at Thyme Care, a value-based oncology management platform. In this role, he focuses on the company’s go-to-market strategies including commercial growth, corporate development and new strategic initiatives. Before joining Thyme Care, Brad served as a Senior Advisor at the Center for Medicare and Medicaid Innovation (CMMI), where he helped lead the development of Medicare’s vision for future total cost of care alternative payment models. Previously, Brad served as Co-Founder and CEO of Herald Health, an early stage health IT startup developing customizable clinical alerting solutions, and later as Associate Vice President for Healthcare and Life Sciences at Persistent Systems, a large IT vendor that acquired Herald Health. Dr. Diephuis is clinically trained in internal medicine from Brigham and Women’s Hospital and has received an BA/MS in electrical engineering and computer science, and an MD/MBA degree from Harvard University. Brad maintains a small primary care practice in Boston, MA.
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