How would healthcare reform impact cancer care delivery and reimbursement? Will value-based models push for a more integrated and ideal care delivery for oncology patients?

Rebekkah Schear, MIA, thinks that the Oncology Care Model (OCM) is a good start and its impact will become clear over time. However, she does expect to see a positive impact on navigation care planning, with the patient at the center of the process. “We are moving from “an illness-centered perspective toward a person-centered perspective,” Schear said.

Michael Kolodziej, MD, said that he too, is looking forward to learning what implementation of the OCM will do, as data would be scrutinized for quality and process improvement while keeping the patient front and center. “The idea that you do things because this is the way we do things, and the patient’s kind of peripheral to all this, that’s disappearing,” he added.

"I think what we're seeing, and I hope will continue to be seen, is that patient centeredness is the point," Schear said, adding that "all opportunities moving forward to help patients and families sort of articulate our humanity and fore care systems evolve towards supporting patients in their individuality and to really look at holistic healing—healing's in the perspective of this multidimensional place and looking at people."

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Can care delivery and payment reform in healthcare help tide us over the existing gaps in cancer care?

Segment 9 - Impact of Healthcare Reform on Cancer Care

Joseph Alvarnas, MD, asked the panels opinion on what they perceive as opportunities for improving survivorship care. "What do you see as the gaps in survivorship care?  You mentioned some of them earlier. What are they and how do we get towards this idea of really preparing patients for their life after cancer?" he asked.

In response, Rebekkah Schear, MIA, shared results of a LIVE

survey from several years ago that found that a majority of patients had at least 1 posttreatment physical, emotional, or practical concern. However, 29% said they did not receive care for their physical concerns, nearly 50% voiced lack of follow-up care for their emotional concerns, and one-third did not get follow-up care for practical concerns. Less than half of the patients reported having conversations on fertility preservation and fertility risk with their provider. "I think that across the board we're seeing the needle begin to move a little bit in terms of survivorship evolving as a movement," Schear said.

Lending his experience as an oncologist to the discussion, Michael Kolodziej, MD, said that a lot remains unknown with chemotherapy agents. He cited examples of patients with breast cancer whom he had treated about 2 decades ago and who were concerned about cardiac effects post treatment with Adriamycin or Herceptin—drugs known to be cardiotoxic. He said he was at a loss for information because not much was known back then about survivorship care. In his opinion, primary care providers need to play a much bigger role in caring for patients who have survived a cancer diagnosis and treatment.

"If we can start to develop the evidence base that will allow us to give good recommendations to our patients and to our primary care physician colleagues, we'll actually improve the life and promote the wellness of our patients for a long, long time," Kolodziej said.

How can care providers ensure cancer survivors continue to receive adequate follow-up care post treatment?

Segment 8 - Covering the Gaps in Cancer Survivor Care

"The issue of advanced care planning, end of life, and hospice which were earlier raised I think are also a challenge for many oncologists," said Joseph Alvarnas, MD. He cited a study published in 

revealed that there is discordant understanding on the prognosis between the physician and the patient. The patients seemed to be more optimistic about their survival prognosis, while the oncologists may not.  Alvarnas wanted to know how this could be rectified.

Rebekkah Schear, MIA, narrated the story of a friend who lost her father to cancer and then her mother was re-diagnosed. The family could not agree on the treatment plan, especially when deciding on the mother’s transition from active treatment to hospice. "I think that's it a very emotional, challenging subject and the experience of family members and the dynamics of families plays into that in a significant way." She added that a nurse navigator or a social worker can play an extremely important role in guiding the family through the process.

Going back to her friend's story, Schear said, "I got on the phone with a 3-season nurse navigator who had been working in oncology for over 25 years, and with her sisters we sort of helped them the set of questions that they should be asking the rest of the family and also questions to pose to their mom about what she wanted as her cancer journey came to a place where it was and as her prognosis worsened."

Michael Kolodziej, MD, said that as he looks at this now as an outsider who’s been there, he realizes how certain aspects of care are managed very poorly or not handled at the right time. “We do it when we’re facing a crisis typically. That’s not when you get the most responsive, receptive, constructive dialogue necessarily going.” The entire treatment plan should be addressed right up front, and the opinions of the family members should also be given consideration. 

When asked if CMS coverage for discussions on advance care planning for Medicare patients would push this process, Kolodziej said he didn't think so.

How can discussions on advance care planning and end-of-life care be successfully broached with patients and their family members?

Segment 7 - Successful Discussions on Advance Care Planning and EOL

When asked how payment models can be developed that ensure care delivery is patient-centered, Michael Kolodziej, MD, said he is not worried about the reimbursement, rather he is "worried more about the operations. I'm worried a little bit about culture change within the practice."

 He explained, "As we go towards a value-based reimbursement methodology, it's absolutely crystal clear to me that if we can execute on behavioral health, for example, or execute on advanced care planning and end-of-life care, palliative care, it's going to actually generate savings for the healthcare system at large. It's going to improve patient satisfaction.  It'll improve patient outcome and there'll be a wonderful win."

Kolodziej believes its more important to develop better care strategies for patients. "I think ultimately doctors will find it's a great way to change how care is delivered," he added.

Rebekkah Schear, MIA, agreed, highlighting the importance of patient and family education, particularly for important process like palliative care. "Palliation in and of itself, I think, is misunderstood and highly stigmatized, especially in cancer care," she said. "But we know that when patients and families have a thorough and more robust understanding of how pain management and palliation can actually improve quality of life, regardless of whether someone might be living with disease for a good chunk of the remainder of their cancer journey or whether they have advanced-stage cancer and they're treating pain and working to improve quality of life all throughout," Schear added.  

The discussion then moved on to the importance that of a care navigator to the process. Kolodziej said, however, that there is not standard definition of a navigator. "I actually like thinking about  a navigator, or more precisely navigator function, in the context of team-based care," he added.

Panelists discussed how patient-centered care can be valuated in the changing healthcare climate.

Segment 6 - Reimbursing Value-Based Oncology Care

"What does a good patient portal look like so that these technologies and this care coordination can be accessible to a broad set of constituencies?" Joseph Alvarnas, MD, asked the panelists. "Does anybody do this well?"

According to Rebekka Schear, MIA, while a lot of the existing platforms are technically sound, what they are missing are a more holistic approach to patient care. "If you look at a lot of what Epic offers, you've got the ability to in many cases send an e-mail to your provider. You've got a patient profile. Your information is constantly updated. You can go in and access and update it. Your medication history is on there. You can send a confidential or private message and things like that," she said.

"But I think what we're missing is that holistic patient perspective. What I think from my perspective what we've literally done is just taken the very 2-dimensional nature of a patient and then sort of projected it into this digital dimension," she added. Schear would like to see health information platforms reflect the values of the patient.

Michael Kolodziej, MD, added that the patient portals "were note really built to be useful to the patient. That wasn't the intention. The intention was to meet meaningful use criteria. I think that perspective is in the process of change." 

Is there anything like an ideal patient portal that can cater to a broad range of patients? According to Rebekkah Schear, MIA, what patient portals lack is a holistic approach toward the patient. 

Segment 5 - An Ideal Patient Portal

Joseph Alvarnas, MD, asked the panelists' thoughts on a proposed timeline for when patients and the healthcare system could anticipate a technological fix to the existing problem of interoperability.

Rebekkah Schear, MIA, said that several patient-friendly apps have been developed that ensure patients have access to their health information and a line of communication with their care provider. Schear also highlighted the importance of wearable devices for a more real-time sharing of patient information with their care provider(s). 

"I think the general point is there has to be a balance between having immediate access to most things in our lives from a communications perspective and knowing that the health sector is going to be a little bit slower to catch up," Schear said. "But at the same time, we need to overcome this thick barrier between providers and patients where provides aren't necessarily able and available to connect with patients with immediacy. There needs to be some sort of balance there," she added.

Both Schear and Michael Kolodziej, MD, agreed that the evolution of HIPAA is inevitable and it has to keep pace with the technological advances within healthcare.

How can we create more standardized health information platforms that can easily exchange patient information?

Segment 4 - Overcoming Barriers With Data Exchange

"Patients may see many providers, including their primary care physician, the oncologist, a radiation oncologist, a pharmacy, and a slew of others, all of whom contribute immeasurably to the process,' said Joseph Alvarnas, MD. But who should carry the responsibility to navigate the patient through the entire cancer care journey, he asked.

Rebekkah Schear, MIA, agreed with Alvarnas that although there have been big strides on ideas for care coordination, implementation barriers exist. A very common encounter for patients, she said, is lack of communication between 2 of their providers who might be part of 2 different healthcare systems. "It's not uncommon that we hear that the patient and their family and caregivers are sort of being bumped around between their primary care provider, between the social worker that might be supporting them, their counselor or psychosocial expert, and their oncologist, the surgical expert, the surgeon that's helping them in addition to any of the other sort of non-clinical providers that are providing support practically and financially as well," she added.

Schear believes that trying to harmonize the team is very important and that reimbursement policies for the navigators, care managers, and the services is a necessary and important amendment for oncology care policies.

Michael Kolodziej, MD, added that care models such as the Oncology Care Model have set aside payment for a care navigator, but he is a firm believer that technology can play a vital role in this process. He emphasized, however, that we need to revamp the fragmentation that exists within information technology (IT) platforms.

Cancer is a complex disease to treat an patients can be overwhelmed by the number of care providers that they have to consult with. In this scenario, care navigators can provide significant support to patients and their family members.

Segment 3 - Challenges With Oncology Care Navigation

Joe Alvarnas, MD, asked Michael Kolodziej, MD, to provide insight on the importance of documenting the treatment plan for cancer patients, an objective of the Planning Actively for Cancer Treatment or PACT Act. 

Kolodziej emphasized that documentation and processes of care, especially for emergency department visits and inpatient stay, are very important for both the patient and caregiver to understand how care will be managed. "As we think about healthcare reform, integrated delivery systems, and coordination of care, the communication between physicians is often poor," he said. "Some standard methodology for communicating information across the patient's multiple care management teams—and that is especially true in Medicare&mdash;becomes really, really vital to a good outcome."

Rebekkah Schear, MIA, agreed, adding that documenting the treatment plan creates functionality for patients, particularly post treatment. She added, that all providers, particularly the primary care providers, should be aware and integrate the patient’s current treatment with reference to what they have gone through for their cancer care. “That’s not just physically, but emotionally. The psychosocial perspective is critical,” said Schear.

 in 2015 Schear said, "Only 29% of respondents to the survey—and these were all patients and survivors&mdash;noted that they even received a written summary of their cancer treatment. Further, only 17% noted that they had difficult care plans."  

	"Our data shows that patients will use care plans and treatment summaries to understand long-term effects of the treatment that they might experience and over 50% have told us that they use it to know what cancers they should be tested for moving forward," Schear added.

Panelists discuss the need for documenting a treatment plan early in patient care. 

Segment 2 - Documenting the Treatment Plan

To discuss this progress and what is currently lacking in care practices in oncology, 

 invited Rebekkah Schear, MIA, director of mission delivery at the LIVE

 Foundation, and Michael Kolodziej, MD, former national medical director of oncology strategies at Aetna and currently the national medical director of Managed Care Strategy at Flatiron Health. The telepanel was moderated by Joseph Alvarnas, MD, editor-in-chief of 

. Alvarnas is associate clinical professor and director of medical quality, risk, and regulatory management, City of Hope, Duarte, California.

The panel began with Alvarnas asking each participant to define what patient-centeredness and shared decision making mean in oncology care. "There's a lot that I think I can articulate when we talk about how patients and families can be engaged in discussions on treatment planning," Schear said. "But really what I think we're seeing in terms of paradigm shift around oncology in particular, is that patient-centeredness is becoming the new paradigm for how care is to be delivered."

Kolodziej explained that oncologists believe they are doing a perfectly fine job in educating patients and including them in treatment decisions. Payers, on the other hand, do not have much insight into how well this is being implemented by oncologists, but he agreed with Schear that there are shortcomings to the process. “The biggest shortcoming really boils down to the fact that when a newly-diagnosed patient comes into your office with, or without, supportive family members or friends, there is just such a knowledge gradient and it’s such a loaded conversation. It’s very hard to process it,” Kolodziej said.

Kolodziej believes that the provisions within payment models such as the Oncology Care Model can help provide patients access to their treatment plan. 

Joseph Alvarnas, MD, editor-in-chief of Evidence-Based-OncologyTM spoke with Rebekkah Schear, MIA, and Michael Kolodziej, MD, to discuss the progress and challenges in oncology care. 

Segment 1 - Patient-Centered Care and Shared Decisions in Oncology

Although there are a lot of quality measures currently available, are there gaps that need to be filled? Jennifer Malin, MD, staff vice president, Clinical Strategy, Anthem, said that while there are a lot of quality measures, with ASCO taking a lead in developing these, gaps persist. “Some of the quality measures are maybe too general to really differentiate high quality and low quality care,” Malin said, adding that measures might be too general to end up being meaningful.

There’s also the possibility of measure fatigue, especially in cancer, with its many subtypes, with specific treatments for each. What would be ideal, Malin said, would be the development of cross-cutting measures, such as Anthem’s approach for pathways adherence, which helps measure if the most appropriate treatment is being delivered. “The issue is coming up with a succinct number of measures that are really meaningful. It’s hard to do that with 200, but at the same time you need measures that don’t leave rare cancers, where arguably it’s the biggest challenge in making sure people get appropriate care, out of the picture,” Malin added.

Jason C. Goldwater, MA, MPA, senior director, National Quality Forum (NQF), agreed with Malin that care gaps do exist, and explained how NQF is working to explore these breaks and workout ways to fill them up. NQF, Goldwater said, facilitates and leads the Measure Application Partnership, which “brings together a lot of national experts in the area of oncology, again, from numerous sectors from payers to providers to consumers and so forth that talk about the measure gaps and talk about the measures that are needed.” The resulting recommendations are then turned in to the CMS with the hope of being commissioned.

Goldwater specifically discussed gaps in palliative and end-of-life care and also being able to understand disparities in cancer care, driven by socioeconomic and other factors. This, he believes, can help direct efforts in the right direction. “I think that we're still evolving that area and still working through to understand what we can best do to fill those gaps whether they come through a CMS sponsored project or whether they come from an organization's own initiative to determine whether or not that gap can be identified and filled and filled in such a way that it would create a sustainable metric that would be able to be used and evolved over time,” Goldwater added.

Linda Bosserman, MD, assistant clinical professor and staff physician, City of Hope, is hopeful about Anthem’s efforts to provide patient outcomes data to the individual physician or clinic—whether they visited the emergency room or the hospital, the frequency of the visits, etc. this information, Bosserman said, is usually not available in real-time to the clinic, unless they have a system in place that queries the patient on it. “It's really going to take this larger partnership, partnership between the primary doctors. How are we looking at overall health outcomes at the primary care levels…the hospital, the emergency room, and then how do we tie in hospice and palliative care in more effective ways. There are a lot of gaps and huge opportunities,” Bosserman said. These conversations between providers and payers can push us toward solutions, she said. 

Jennifer Malin, MD, staff vice president, Clinical Strategy, Anthem, said that while there are a lot of quality measures being developed by several organizations, care gaps persist.

Segment 11: Confronting Gaps in Care Measurement

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