Using Value-Based Compensation to Control Costs

Solving the problem of financial toxicity “is going to be very difficult,” said Cary J. Stimson, MD, of Vanderbilt University Medical Center in Nashville, Tennessee, when giving a related presentation at ASCO GU 2023.2 

However, Dr Stimson suggested that providing value-based care could be a solution. He defined value-based care as “paying for health care that works” and said value is determined by dividing outcomes by the amount spent. He said clinicians provide value-based care when they accept financial risk for the costs of care.

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To explore how that can work, Dr Stimson reviewed payment models and the accompanying risk to providers. With “fee-for-service,” there is no financial risk and no incentive for providers to reduce costs. With “pay for performance,” providers receive fees for their services, supplemented with bonus compensation for achieving contractually defined metrics. 

“Bundled payment” programs require providers to assume responsibility for the outcomes and costs of an entire patient-specific event. A hypothetical example would be assuming the responsibility for the 90-day period during and after radical cystectomy. 

With the “population-level payment” model (the highest level of risk), providers are compensated with a monthly fee for managing all required care for a panel of patients.

Dr Stimson also cited specific examples in which value-based principles were applied to the diagnosis, staging, treatment, and surveillance of bladder cancer. In those examples, researchers and/or regulatory agencies identified interventions in which outcomes justified or did not justify additive costs, in comparison with less costly interventions.

One study showed that photodynamic diagnosis-guided transurethral resection of bladder tumor did not reduce recurrences and was not likely to be cost-effective, when compared with white light, at 3 years.6 Another study showed that alvimopan can accelerate gastrointestinal recovery after radical cystectomy, thereby shortening the hospital stay and reducing costs.7

Dr Stimson also noted that the Oncology Care Model is an example of a failed opportunity to control the costs of cancer care. The program lost $377.1 million overall in its initial 5 years. 

“What we got wrong at Medicare — I was heavily involved with this program — is that we were paying practices too much to support the care of those patients,” Dr Stimson said. “So I would say that this did not work, and we know it didn’t work because now CMS has removed bladder cancer from their bundled payment approach.”

Still, Dr Stimson said, there are “value opportunities” in bladder cancer care, “and we need to seek those out and understand them better.”

Facilitating Health Equity and Quality Outcomes

Dr Stimson’s presentation highlighted that optimizing diagnostic procedures, surveillance, and treatment could potentially decrease the financial burden for patients with bladder cancer. This could improve patient outcomes and reduce the societal impact from direct and indirect costs of care, according to Dr Sharma.

Dr Sharma also suggested that costs of care should be discussed openly with patients. This includes relative costs, benefits, and harms of guideline-concordant options for care. 

The 2-fold results of shared decision-making discussions should be:

  • To develop risk-stratified plans that tailor surveillance and therapy to patients who benefit most from particular interventions and surveillance schedules
  • To refer high-risk individuals to social workers and financial navigators who can provide them with the resources they need to minimize financial distress.

Disclosures: Dr Sharma disclosed relationships with Immunity Bio. Dr Stimson did not disclose any conflicts of interest.


1. Sharma V. The impact of the financial cost: How much is it costing our patients with bladder cancer? ASCO GU 2023.February 16-18, 2023.

2. Stimson, CJ. It’s time to talk about value-based care and time toxicity with our patients. ASCO GU 2023. February 16-18, 2023.  

3. Mariotto AB, Enewold L, Zhao J, et al. Medical care costs associated with cancer survivorship in the United States. Cancer Epidemiol Biomarkers Prev. 2020;29(7):1304-1312. doi:10.1158/1055-9965.EPI-19-1534

4. Yabroff KR, Lund J, Kepka D, Mariotto A. Economic burden of cancer in the United States: Estimates, projections, and future research. Cancer Epidemiol Biomarkers Prev. 2011;20(10):2006-14. doi:10.1158/1055-9965.EPI-11-0650

5. Castilla-Lennon MM, Choi SK, Deal AM, et al. Financial toxicity among patients with bladder cancer: Reasons for delay in care and effect on quality of life. J Urol. 2018;199(5):1166-1173. doi:10.1016/j.juro.2017.10.049

6. Heer R, Lewis R, Duncan A, et al. Photodynamic versus white-light-guided resection of first-diagnosis non-muscle-invasive bladder cancer: PHOTO RCT. Health Technol Assess. 2022;26(40):1-144. doi:10.3310/PLPU1526

7. Lee CT, Chang SS, Kamat AM, et al. Alvimopan accelerates gastrointestinal recovery after radical cystectomy: a multicenter randomized placebo-controlled trial. Eur Urol. 2014;66(2):265-72. doi:10.1016/j.eururo.2014.02.036