Countering the Misincentivization of Cancer Medicine by Real-Time Personal Professional Education

In the United States, public and private payer misincentivization of medical care and the invisibility of costs to the consumers of that care have conspired to create unsustainable growth in health care expenditure that undermines our economy, diminishes our productivity, and limits our international competitiveness. Cancer medicine provides a small yet salient example. On average, Medicare reimburses oncologists 6% above the average acquisition price for essential anticancer agents and supportive therapies. The costs of these agents vary across a stunning five orders of magnitude, from a few dollars to more than $400,000 per course of treatment. The profitability to providers varies across approximately four orders of magnitude, from cents to thousands of dollars per treatment. National guidelines (National Comprehensive Cancer Network [NCCN], American Society of Clinical Oncology [ASCO]) help providers select the most effective therapies without regard for cost.

We created an oncologist-to-oncologist professional education program to help cancer physicians optimally use expensive long-acting white blood cell growth factors, in accordance with these national guidelines. We then compared their use across a population of approximately 97,000 Medicare members before and after our intervention. Baseline use was recorded over two consecutive quarters (2009 to 2010). In March 2010, our oncologists initiated real-time discussions with the oncologists of 22 separate groups if these agents were ordered for use with regimens that placed patients at less than 10% risk of febrile neutropenia, according to NCCN guidelines. Neither NCCN nor ASCO recommend the routine use of these agents in this low-risk group. The care of 82 such patients was thoroughly discussed in the following 6 months.

The monthly costs for these agents decreased by more than 50% by the final month of our intervention, although savings began immediately, reducing costs by more than $150,000 per quarter. No episode of febrile neutropenia was recorded in any patient in the intervention group. These savings generalize to the entire Medicare population at $30 million each month.

We conclude that personal, oncologist-to-oncologist, real-time professional education will favorably modify oncologic prescribing behavior and can do so with significant immediate savings at no risk to patients with cancer.