Concrete options and ideas for increasing value in oncology care: the view from one trench.

In the U.S., medical oncology as a profession is wrestling with conflicting and often unrealistic clinical and financial expectations. Office-based practitioners face an environment of low reimbursement for cognitive care, high but declining reimbursement for chemotherapy and supportive care, and high income expectations of oncology professionals. As a field, there has been little incentive to assess or improve the quality of cancer care. Current incentives are often misaligned to reward doing the most aggressive and expensive actions, as long as patients are satisfied, because this leads to the highest return to the practice. Some consequences include U.S. cancer treatment costs that are twice that of any other nation with no or minimal differences in survival, late referrals (if at all) to hospice, and 14%-20% of patients receiving chemotherapy within 14 days of their death when it is highly likely to harm and cause complications. This pattern of care may lead to a significant risk for stress and burnout, as well as being economically unsustainable. Systematic change to reward value requires realignment of incentives to provide episode-based care free from incentives to give expensive chemotherapy or supportive care drugs without good evidence, and an external board to determine appropriate patterns of care. The only ways to reduce the cost of care are to reduce either the amount of care or the cost of care, and either has dramatic consequences in a field that has been built on high expectations. These actions will likely control costs, but in the short term will cause significant distress among patients, families, and health care practitioners.