Trading Conflict for Synergy: The New Normal for Oncology and Palliative Care
Michael D. Fratkin, MD
When the ground shifts under your feet, it’s best to shift with it or you will fall…hard. Economic incentives are being turned upside down and a seismic change is approaching. The healthcare system that the current fee-for-service model has spawned will be unrecognizable in 5 years. In times of change like this, it is wise to invest in the future rather than the past. The most important stakeholders—patients, families, and caregivers—have been suffering. Those of us who are professionals dedicated to their well-being, have been suffering too. That’s why we built ResolutionCare,1 a community-based, home-centered palliative care program in rural Northern California. As a palliative care specialist embedded in a community medical oncology program with only 2 oncologists, my professional suffering entailed being overwhelmed with too many consultation requests and very little support. I could only see 1 out of 4 late stage cancer patients referred, which meant constantly triaging to determine who had the most dire symptoms and psychosocial distress. Much of my time was spent choosing which patients with dismal symptoms I would see, and how many nights would I fail to put my children to bed. One morning, I went to wake up my 9-year-old daughter, Bella. When she opened her eyes, she said, matter-of-factly, “Goodbye Daddy.”
Nope. Not me. I am not a “goodbye Daddy” Daddy. I knew that something had to change.
What we were missing at our practice was a team, and what was needed was a way to pay for that team. Palliative care, like cancer care, is best accomplished by a coordinated interdisciplinary team that encourages multiple perspectives from dedicated and inspired professionals who work together to deliver value to patients on their own terms. Because the payment model is fee-for-service, a palliative care doctor can’t generate the revenue required to support his or her own salary, let alone support a team of professionals. Despite the value a palliative care team can bring to a patient with a serious illness such as cancer, and their families, as well as to oncologists and their professional teams, I failed to secure funding for a medical assistant, let alone a nurse, social worker, chaplain, or administrative help—just the familiar refrain to “do more with less.” As many doctors are aware, when physician billing is the only engine for generating revenue, it is more likely that things will get done to patients than for them. Also, providers burn out like crazy and treat one another poorly.
IMPROVING VALUE WITH REFINED PAYMENT MODELS
Value-based payment models are imminent, and we must be equipped to make that fresh approach work for all of us—centering care on the patients and ensuring sustainable work for the professionals they count on. Since teamwork by coordinated professionals is technically necessary to deliver comprehensive care to cancer patients, doesn’t it make sense to pay on the basis of an agreed-upon goal? Additionally, doesn’t it make sense to define that goal with the patient at its center? In our eternal battle with payers, it never occurs to us that if we are all committed to patient-centered care, our interests are entirely aligned. The Triple Aim of improved quality of life, improved patient experience, and reduced costs defines value in terms that get us all to the table. Integrated, team-based palliative and cancer care can’t help bringing value to patients and their families by much more effectively managing symptoms, extending life when possible, and replacing desperation-driven expenditures with value-based support.2 We are swiftly met by improved performance status, less distressed patients and families, and even longer survival.3 Because integrated palliative and cancer care is less costly, the sustainability of care delivery is as important to payers as it is to you, your patients, and our care teams.
WHO WE ARE
ResolutionCare is here to help by extending the capacity for community palliative care in California and supporting oncology practices as they work hard to improve the basic palliative care skills of their teams. At its heart, ResolutionCare is an independent rural palliative care team. But we are also a tandem social enterprise consisting of:
• a community-based, home-centered clinical practice structured as ResolutionCare PC, and
• a distinct educational nonprofit entity, ResolutionCare Fund (a scally sponsored project of Community Initiatives, a 501(c) 3 organization).4,5
Both have the same mission: “Bringing capable and compassionate care to everyone everywhere as they approach the completion of life.” ResolutionCare PC offers people with serious illness access to specialty palliative care clinical services in their homes through the innovative use of videoconferencing, a nimble interdisciplinary team, and value-based payment models. ResolutionCare Fund uses the same videoconferencing technology and interdisciplinary team through a rigorously defined Resource Sharing Agreement. As a licensed affiliate/partner with the University of New Mexico’s Project ECHO model,6,7 we will use this powerful learning model to enhance the basic palliative care skill set of a diversity of healthcare providers in a diversity of practice settings where people with serious illness receive care, like medical oncology practices and cancer care programs.
By using videoconferencing, our clinical programs have “rediscovered” the power and impact of house calls. Some cancer patients will make more than 150 trips in the last year of life for infusions, physician appointments, lab draws, imaging, and fractionated radiotherapy. Faced with these numbers, it is not surprising that patients love house calls when they have the opportunity, and they view a videoconference with their provider as a very similar experience.8 From a professional’s perspective, it’s the rule rather than the exception that vexing problems are clarified and that practical and relevant information is reliably and almost instantly gained in this way. For example, upon walking in the door, you might see how badly confused your patient is with the jumble of medications accumulated over years of fragmented care, or perhaps discover the drug-diverting dependent son whom you hadn’t known existed. Whether the house call is virtual or face-to-face, whether it is performed by trained community health workers, nurses, social workers, chaplains, or physicians, this approach eliminates the expense associated with the infrastructure of an outpatient clinic and puts the resources thus freed up to work for people with cancer in more efficient ways. By the way, home-based, community-centered palliative care saves money…tons of the stuff! That’s why CMS,9 the California Healthcare Foundation,10 Cambia Health Foundation,11 Partnership Health Plan of California,12 and many other insurers are investing heavily in community-based specialty palliative care, value-driven payment models, and collaborations that put more and better basic palliative care skills (symptom control, advanced care planning, shared decision making, etc) to work for cancer patients. Our educational programs are built on the solid foundation of Project ECHO, a powerful and disruptive innovation in knowledge sharing that “demonopolizes” expertise. Project ECHO is a case-based learning approach that leverages videoconferencing technology, linking the scarce resource of a specialty team (eg, palliative care team) with up to 10 teams (eg, oncology practices) in a hub-and-spoke fashion. Applied to a busy community oncology practice, the oncology team at the spoke might consist of clinic and infusion nurses, midlevel practitioners, practice managers, and oncologists, as available. A typical schedule involves up to 6 case presentations, deidentified and prepared by the various linked oncology teams. Meeting twice monthly for 90 minutes (including a didactic component for CEU/ CME), the value accumulates quickly as knowledge and insight move bidirectionally from oncology to palliative care and vice versa, not to mention from oncology spoke to oncology spoke. Through rigorous data collection and analysis, ResolutionCare hopes to demonstrate that oncology practices will track the improved quality of life, satisfaction, and perhaps even duration of survival of the patients in participating oncology practices. In addition, ResolutionCare’s programs are designed to study how our interventions are at least cost neutral. Most likely, the payers will enjoy substantial cost savings and an excellent return on investment. We are also committed to making certain that all cancer professionals—medical oncologists, surgical oncologists, radiation oncologists, oncology nurses, nurse practitioners, and primary care providers—feel better and enjoy the satisfaction that comes from being a part of an integrated team.
Should we defend the status quo in the face of the demographic tsunami of aging Baby Boomers, the unsustainable stratospheric costs of cancer care, and the challenges and dissatisfaction of our cancer patients and colleagues when we simply want the best for all involved? I think it’s best if doctors and allied cancer professionals work together synergistically and invest in the future with innovation, taking care of our teams and of us. If ResolutionCare can be of assistance, we are honored to lend a hand. If you are interested in helping ResolutionCare to find the funding for this bold innovation, please lend us yours. EBO