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Evidence-Based Oncology October 2016
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Making Oncologists Good Neighbors

Michael Kolodziej, MD
Where do we lack in cancer care today and what steps can we take to improve care delivery? Care coordination can be an important lead.
While actively treating cancer patients for their malignancies, oncologists like to take full ownership of the medical care for their patients. Because so much of cancer care is highly specialized, this makes a lot of sense. But it is not unusual for lines of communication between doctors, doctors and patients, and doctors and family members to break down. Every oncologist has stories about missed handoffs. Every patient can recount, in excruciating detail, all the times their doctors did not make an important phone call. If we are aiming for the best patient outcome and the best patient experience, we aren’t even close to hitting the mark. And to my knowledge, no one is taking ownership of this problem.
 
This lack of care coordination will become a crisis as care moves to integrated delivery systems, like accountable care organizations (ACOs). The rationale behind these arrangements is that by forcing an organization to assume both clinical and financial responsibility, all of the interested parties will become engaged, as they will be at risk for a bad outcome. However, even a superficial analysis of how these programs are evolving reveals the obvious problem: specialists—who take care of the most complicated and most expensive (and, therefore, the most critical) patients—are marginalized. Additionally, under most models, an ACO does not exist without a panel of specialists. Layer on the often-strained relationships between hospital administrators and specialists, as well as those between primary care physicians (PCPs) and specialists, and the challenge gets even more acute. There is an expectation that in this “medical neighborhood,” specialists will be good neighbors.
 
Identifying the Greater Evil
Where is the need for coordination greatest? Although I specifically list 4 scenarios, I am sure there are many more:
 
1.       Streamlining patient referral.
Referral for specialist care is a dysfunctional process. Bidirectional and accurate communication between the referring physician and the oncologist is key and works better than giving the patient a stack of papers with the kernels of truth buried deep. A methodology for electronic triage would be a really useful tool. Let’s give patients access to all electronic communication relevant to their case. Interestingly, many virtual second opinion programs do just this, following completion of a virtual case report form. Currently, it is a manual process, but it doesn’t have to be.
 
For patients that do require the consultant’s care, a navigator can be a priceless (and, ultimately, deeply loved and appreciated) patient partner on the care journey. And remember that in an integrated network, there will be a strong disincentive to referral as consultants consume resources. So good communication as to why consultation is not required will be just as important. The result: ACO savings, transparent evaluation, potentially better quality of care, and happier patients.
 
2.       Managing the patient with complex comorbidities.
A second obvious area currently lacking coordination is the treatment of patients with complex comorbidities. These patients pose major challenges for the oncologist for several reasons:
  • They take up a lot of the healthcare provider’s time
  • They frequently suffer complications
  • The oncologist is ill-suited to manage some of the medical problems
The current default—referral back to the PCP or another specialist—is highly inefficient, often inconvenient (and sometimes costly) for the patient, and invariably accompanied by poor communication of the clinical ask. This is certainly a cause of unnecessary hospitalizations, and it certainly makes patients deeply unhappy. The easy target is the darn doctor...if only they would just get on the phone. But that has always been the solution, and it hasn’t worked very well. The solution here is probably adoption of a care team mentality. There is little doubt that a skilled nurse practitioner can facilitate the hand-off of these complicated patients on both ends of the transaction. Again, an electronic solution would make things so much better.
 
3.       Optimizing end-of-life care.
Advanced care planning discussions are very difficult and not particularly enjoyable for many. Evidence shows that many oncologists do not do a very good job with this,1 even though they steadfastly maintain that they “own” these discussions and become irate if someone else has the audacity to intervene. Now, with the evidence that palliative care providers significantly improve patient care at the end of life, there is need for facilitating their access to these patients (and, with that, the need to coordinate care).
 
Besides the obvious need for oncologists to “get over” their territorialism, effective integration of these providers into the care team will unquestionably improve the quality of care throughout the care continuum and likely reduce costs. There is no doubt that if oncologists do not solve this problem, the integrated delivery system will do it for them—and patients will like it (or so the data say).1 Do not forget that the PCPs also need to be kept in the loop. For many patients, these doctors manage families across generations and enjoy tremendous trust and respect. Again, an electronic solution appears needed.
 


 
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