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The Carrot or the Stick? Integrating Palliative Care Into Oncology Practice
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The Carrot or the Stick? Integrating Palliative Care Into Oncology Practice

Torrie K. Fields, MPH
As cancer care moves to payment focused on improving value, payers are more often using regulation and incentive to improve the integration of palliative care into oncology practice.
In an era with increased emphasis on bending the cost curve while increasing availability of targeted therapies for those with cancer, it can be difficult to strike the right balance between the art and the science of practicing high-quality oncology care. Perhaps just as difficult is the role of a regulating body or healthcare financer in providing the right incentives, policies, and authorization practices that allow clinical judgment while ensuring treatments are of high quality, evidence-based, and align with patient preferences. As cancer interventions become more effective and more complex, it is essential to create guardrails and incentives so that high-quality, patient-centered, cost-effective healthcare continues to be delivered.

Integrating palliative care into a treatment plan, preferably at the point of diagnosis, is crucial to delivering high-quality cancer care. Palliative care—which focuses on relieving the pain, symptoms, and stresses of a serious illness—has the ability to change the delivery and experience of healthcare for patients and caregivers. Many prospective studies have shown that when integrated early in the treatment process, palliative care is associated with an increase in quality of life, satisfaction with care, an improvement in symptom burden for both patients and caregivers,1-3 and longer survival.2 While the evidence for palliative care has been compelling, the integration of palliative care into cancer care is moving slowly, requiring considerable changes in paradigm and ideology for oncologists as well as shifts in process flows for their practices. As financing for cancer care begins to shift from fee-for-service (FFS) to value-based payments, payers have an opportunity to incentivize and regulate services provided to patients and their families that can support oncology teams to provide high-quality care transitions for cancer patients in any stage of disease—from point of diagnosis, through treatment, and nearing end of life or survivorship.

Current State of Cancer Care

Economist Michael Porter defines value in healthcare as “patient health outcomes achieved per dollar spent,” emphasizing that the health outcomes achieved should focus on the patient’s preferences and defined measures for success, rather than strictly clinical effectiveness of treatment or survival rate.4 FFS cancer care does not factor in the quality of care provided and largely emphasizes impetus towards providing costlier and more aggressive services, thereby straining the healthcare system with the cost of experimental and targeted therapies and increasing the exposure of financial toxicity on patients and caregivers. Often, these treatments are in direct opposition to patient preferences.5 Even with health insurance, 10% of Medicare beneficiaries without supplemental insurance have been found to spend over 60% of their annual income on out-of-pocket expenses following cancer diagnosis.6 Twenty-five percent of participants in a Kaiser Family Foundation study reported using all or most of their savings dealing with cancer, while 33% of families reported a problem paying their cancer-care bills.7

Despite the variability in quality of care and financial impact on patients and caregivers, advances in treatment and precision medicine have increased the number of cancer survivors in the United States.8 With growing urgency to balance the delivery of high-quality cancer care with costs, stakeholders—including the Centers for Medicare & Medicaid Innovation (CMMI)—are developing new financial and clinical models that emphasize value.

Earlier Attempts at Practice Transformation

When moving from clinical-imputed value of treatment to the patient-perceived value of cancer care, it is imperative to include additional domains to determine the overall value of a test, procedure, or treatment. Suffering in cancer patients can be derived from multiple factors, including uncontrolled symptoms, inadequate psychosocial support, financial toxicity, inadequate understanding of prognosis or treatment options, disregard for patient preferences for treatment or setting, or even prolongation of the dying process in terminal cases. In 2012, in an effort to mitigate this, the American Society of Clinical Oncology (ASCO) and the American Board of Internal Medicine Foundation launched, as part of the Choosing Wisely campaign, the top 5 list of tests and procedures in oncology care that should be questioned due to their failure to add further clinical value to the course of cancer treatment for a patient. The list was compiled with input from more than 200 oncologists and was used to promote communication among oncologists about best practices in delivering higher-value care. With 2 procedures highlighting improper management of pain and symptoms under Choosing Wisely, one recommendation from ASCO was earlier integration of palliative care into the treatment plan for those patients with advanced cancer.9

In a retrospective review of this list and of adherence to the Choosing Wisely recommendations, it was found that not only was adherence highly variable, but that aggressive care did not decrease following implementation of these recommendations. Overall adherence to these measures ranged from 53% to 78%, with adherence being poorest for patients diagnosed with advanced cancers. With the palliative care measure in particular, adherence ranged from 60% at 90 days from the date of death to 89% at 14 days from the date of death.10 These results indicate that early integration of palliative care into cancer care is largely nonexistent, with referrals to hospice or palliative care coming consistently only in the last 2 weeks of life. This late-stage integration does not allow a patient or caregiver to experience the full effect of palliative care’s ability to alleviate suffering throughout the care continuum, and it suggests that aggressive, often unwanted, therapy is occurring until the patient is very near death.

Often overlooked as a hurdle to the integration of palliative care into cancer care is that graduate medical education includes only limited training in communication skills and care coordination. This training often does not continue once a new doctor selects a specialty, such as oncology. A considerable amount of evidence suggests that communication skills training in oncology practice has the ability to help healthcare professionals demonstrate feelings of empathy, address stressful and difficult situations, improve care transitions, and improve the quality of medical care and satisfaction for patients and families.11 However, the receipt of such training is dependent upon the interest and initial comfort level of an oncologist to pursue and continue such training on their own time, as part of continuing medical education. This results in a workforce that is highly variable in its ability to communicate with patients and families about prognosis, treatment goals, or the clinical value of cancer treatment being administered.

Practice transformation is also limited by the variability in quantifiable process and outcome measures being used by all value-based purchasing programs, including those for cancer care. In a review of 129 publicly available value-based purchasing programs, the Rand Institute found that there is a high degree of variability in measures chosen for clinical appropriateness of care, patient preferences and satisfaction, and care centered on patient functional status.12 The high level of experimentation in the area of value-based purchasing and bundled payments has generated mixed results on the effectiveness of these types of programs, further increasing the hesitance of providers to transform their practices to achieve stipulated targets. Among those successful programs, the elements determined to improve clinical outcomes included considerable financial incentives and alignment on quality, utilization, and performance targets, as well as provider training, engagement, and support for quality improvement initiatives and reporting requirements in the electronic health record (EHR).12

Blending Incentives and Support to Integrate Palliative Care Into Oncology Practice

The practice of integrating palliative care into oncology practice has been gaining considerable traction with the implementation of bundled payment programs for oncology and the introduction of the Oncology Medical Home (OMH) model.13 Most notable is the implementation of the Oncology Care Model (OCM) by CMMI, a demonstration project focused on improving the value of cancer care for Medicare beneficiaries. OCM and multiple other oncology bundled payment models being piloted throughout the country focus on the use of incentives and reporting criteria to align patients undergoing active cancer treatment to evidence-based pathways and additional support for care coordination. Performance is measured using cost, quality, and patient satisfaction targets.

Bundled payment programs for oncology, including OCM and OMH, require practice transformation (Figure).14,15 While these requirements may be possible to achieve by a larger oncology practice with considerable operational infrastructure and support, independent oncologists and smaller practices may have more difficulty implementing change. Because palliative care teams are focused on providing a team-based approach to care, care coordination, and a multi-dimensional care plan documenting treatment preferences, the integration of palliative care or a partnership with a palliative care team can be used to facilitate practice transformation and provide a higher degree of patient-centered care.16

In addition to bundled payment reimbursement for providing oncology care, payers are experimenting with additional incentives and regulatory criteria to better integrate palliative care into oncology beginning at point of diagnosis. Incentives and regulation range from more standard approaches under value-based purchasing to those that are more innovative in nature, all with considerations that must be weighed prior to implementation.

One standard approach to incentivizing the integration of palliative care into oncology practice is the additional ability for oncology practices to achieve a higher percentage of shared savings or provider performance bonuses based on specific process and quality targets, focusing on this integration. For example, a proposed process measure by which to increase an incentive payout would be the documentation of a medical surrogate for all patients diagnosed with cancer or the documentation of Eastern Cooperative Oncology Group status, both of which are indicators of, or drivers for, early palliative care intervention. An example of a quality outcome measure would be the hospice referral rate or median length of stay (LOS) on hospice for patients with metastatic cancer. By incentivizing the median LOS on hospice, oncologists would need to engage the patient early and often regarding treatment preferences, including preferred place of death. Payers and providers alike must be cautious in measure selection, as not all patients will prefer hospice or wish to die at home, and this must be taken into account in reporting and calculation of incentive payouts.

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