Updates from the Association of Community Cancer Centers annual meeting.
A diverse panel of representatives from several practice models provided insights into what has and has not worked for them in their attempts to improve cancer care. The discussion took place at the Association of Community Cancer Centers’ 45th Annual Meeting & Cancer Center Business Summit, held March 20 to 22 in Washington, DC.
The session kicked off with highlights from the recent Trending Now in Cancer Care survey. Deirdre Saulet, PhD, practice manager at The Advisory Board Company, noted that survey respondents—which included people at nonteaching community hospitals, academic medical centers, and freestanding cancer clinics—identified symptom management, including reduction of emergency department visits, and clinical standardization as 2 of the biggest opportunities for cost savings. Identifying these areas is critical, as healthcare
may follow a fee-for-service model, but it is increasingly moving toward valuebased or outcomes-based payments.
On the flip side, respondents said the biggest return on investment for cancer programs was care coordination, such as navigation.
“It’s not…enough to attract patients to your program anymore. You really need to…shepherd them throughout the process [and] keep them loyal to your system,” Saulet said.
Engaging and Empowering Providers
Each of the panelists described what their practice, program, or company does well. Linda Bosserman, MD, medical oncologist at City of Hope, highlighted the center’s diversity. She noted City of Hope has community centers that are not under 340B, as well as a center that is under 340B; the ability to bring together community oncologists and oncologists in the academic center to compare outcomes; and the push to bring surgeries, research, and treatment closer to the patient at home through telemedicine.
OptumCare Cancer Care, a division of OptumCare, which is a subsidiary of UnitedHealthcare, is developing a multispecialty entity with surgery, radiation oncology, and medical oncology that practices quality care, follows guidelines from the National Comprehensive Cancer Network, and focuses on patient satisfaction, according to Russell Goddard, MD, director of medical oncology. The center is instituting a collaborative approach among nutritionists, psychologists, and palliative care doctors early in a patient’s cancer journey.
As a community practice, The Center for Cancer and Blood Disorders really knows its patients and their experience and what the center can implement to improve that experience, explained Barry Russo, chief executive officer. When the practice noticed it had an issue with palliative care, it pulled in a palliative care expert; when it realized socioeconomic issues were significant for patients, it engaged social workers, dieticians, and others.
“I think we’re nimble enough that we can react fast, we can see what some of the issues are, we get a lot of really direct feedback from patients because of the nature of our relationship…and I think that generates, ultimately, for us, a better product,” Russo said.
Meanwhile, OneOncology, a new organization comprising 3 leading oncology practices—Tennessee Oncology, New York Cancer & Blood Specialists, and West Cancer Center—is empowering physicians in the community and physician-led community oncology practices to succeed. Erich A. Mounce, MSHA, chief operating officer at OneOncology, explained that the organization helps community oncologists gain access to capital, technology, and expertise so they can compete with other entities, including academic institutions and giant not-for-profit hospitals.
“For us, the best care is delivered in the community setting, no matter what, and that’s what we aim to continue,” Mounce said.
Inova Schar Cancer Institute recognized in 2014 that it had few closely associated practices and made a commitment to change based on the realization that the future of cancer care was ambulatory, said Donald L. “Skip” Trump, MD, FACP, chief executive officer and executive director at Inova. Since then, the institute has made progress, developing a model that attempts to be patient centric by listening to patients and putting into place modern technology.
The goal, said Roger Brito, DO, national director of oncology at Aetna, is to be able to use all these different network and practice models to focus on improving patient care overall. No one model is necessarily better than the other—they should be used together, according to Brito.
Saulet added that communication and coordination among each of the groups are crucial and that, as a patient, she wants to know that her providers are all talking and delivering cost-effective, patient-centered care in the appropriate setting.
Room for Change: Care Coordination, Cost Control, Technology
However, no company, practice, or organization is perfect, and moderator Michael Kolodziej, MD, FACP, vice president and chief innovation officer at ADVI, challenged the panelists to acknowledge what they do poorly and need to improve upon.
Trump highlighted the difficulty Inova faced in getting everyone on the same page; Mounce discussed the need for better investment in the workforce; Russo explained that coordination across specialties was difficult, especially with everyone under different reimbursement structures; Goddard pointed to the jigsaw puzzle of providing quality and cost control in a population health model and getting true provider engagement; Russo identified the need for technology support that notifies the practice when a patient enters the emergency department or the outpatient setting; and Bosserman described the challenge of getting molecular data to the bedside and into the fingers of experts in real time.
The panelists finished with a discussion of the Oncology Care Model (OCM). With the exception of Brito, they all believed OCM would continue, perhaps with some evolutionary changes.
Although OCM is not perfect, it has pushed oncologists to examine several aspects of the care process that they were not previously addressing, Russo said. However, his practice has struggled with the model. Despite having a cost of care per case that is on a downward trajectory, The Center for Cancer and Blood Disorders has not been financially successful under the model.
Mounce agreed, saying that OCM has allowed oncology to focus on things they needed to focus on, such as coordinating care, investing in the care of patients throughout their entire journey, and understanding how to incorporate palliative care earlier.
Although Brito thinks OCM makes sense conceptually, he said he does not like the data dumps that go to providers, because they struggle to make sense of the information they receive. In addition, the current model does not do a good job of accounting for novel therapies, said Brito.
“As we look at the data, as [they start] to mature, what we’re seeing is we need to come up with a 2.0, 3.0 strategy because the immunotherapy agents changed the game,” Brito said.
"We don't need new sights; we need new eyes," said healthcare futurist Joe Flower as he opened up the Association of Community Cancer Centers’ 45th Annual Meeting & Cancer Center Business Summit, with a vision of a healthcare system that provides better quality care at a lower cost and is more easily accessible to all stakeholders.
Healthcare is complex, so simple solutions will not work, Flower said. And over the next 10 years, the healthcare industry will experience a turbulent time as a result of multiple factors, ranging from new technologies to economic pressures.
The goal is to remove the current fee-for-service, opaque system and replace it with one that is more efficient and transparent. Those who lead the charge on this will be more attuned to the needs of the market and will excel at building and reshaping the business of care seriously and deeply around the needs of patients and their families, as well as the emerging big buyers of healthcare, Flower said.
Before painting a picture of how the healthcare system could—and should—look in the future, Flower homed in on why these changes are being sought after. The central factor driving all the change the community is seeing, and will continue to see, in healthcare is that it costs too much, he said. This year alone, the United States will spend an estimated $3.9 trillion on healthcare, approximately one-third of which will be waste. And cancer care is the poster child for the extraordinarily shocking cost of healthcare in the country, he said.
Looking at trends over time, Flower pointed out that US healthcare spending started to increase faster than that of other countries in 1983-1984, when diagnosis-related group codes were implemented. Although they were meant as a cost-cutting measure, these codes in effect gave “the industry a manual for how they can make more money” by upcoding and using newer technology with a better International Classification of Diseases, Ninth Revision, code even if the technology was not more expensive, he said.
Flower then presented the audience with a table of elements, including all the facets he said are needed to facilitate this care delivery transformation the industry so often hears about.
“Community cancer centers are generally ahead of the rest of healthcare in these areas because of the nature of cancer care,” said Flower. “In the changed environment, you can look to community cancer centers’ relative skill in these areas as a competitive advantage.”
This new care delivery system begins with behaviors driving such an environment, notably trust, which includes trust between patient and provider as well as among different members of the care team. He also mentioned the phrase commonly cited when envisioning the future of cancer care: patient-centered care, in which the system is built around the patient’s needs. Other drivers include moving from acute treatment to chronic, longitudinal treatment, as well as population heath and community health strategies.
“We know your zip code is a far better predictor of your longevity than your genetic code,” said Flower.
For a system built around these behaviors, team-based care and a standardization of protocols that end unneeded variation in care are crucial. Flower underscored the importance of disintermediation of the entire health system so that physicians won’t have to go through health systems, payers, and employers to access their patients—and vice versa.
Employers have already started to play a more active role1 in their employees’ care, and this trend will continue in the coming decade, with employers looking to deal directly with physicians and penetrate through intermediaries. Flower gave the examples of Haven—the well-known joint venture2 of Amazon, Berkshire Hathaway, and JP Morgan—and Walmart’s continued efforts to get more involved in healthcare.
To sustain this environment, risk must be redistributed and moved away from fee for service and treat to code and toward “transparent and competitive payment models,” such as bundled payment, said Flower. Payment elements of this changed care delivery environment include spot auctions, in which a patient can essentially shop their area for a service, see how much they would pay, read reviews of a provider, and make an appointment online. Flower compared it to booking a hotel or a seat on an airplane.
Lastly, complementing these behaviors, technology will fill gaps in the system. However, Flower emphasized, technology should never become a substitute for human contact. Instead, it should keep the patient directly hooked into the system and facilitate communication across the continuum. Recognizing that interoperability has not yet become a reality, Flower does see it becoming one in the coming decade.
Other elements include technologies like monitoring patches and smart drugs, which will be supported by blockchain, as well as elements the healthcare system has already started introducing into care delivery, such as artificial intelligence, big data, and personalized medicine that fits a patient’s specific needs.
Although no single country has perfected use of digital health, there are some takeaways from what countries around the world are doing successfully, according to John D. Halamka, MD, MS, chief information officer, Beth Israel Deaconess Health System, who presented at the Association of Community Cancer Centers’ 45th Annual Meeting & Cancer Center Business Summit, held March 20 to 22 in Washington, DC.
Halamka recently traveled to 14 countries in 60 days to learn how they are using technology in healthcare and gain insights from other societies. In China, families line up at 4 am at academic medical centers to get treatment because they don’t think the community is the place where they should get care and they don’t have primary care doctors. According to Halamka, there is no order to the medical system, so President Xi Jinping came up with the idea of examining past experiences of patients to inform how patients should experience care in the future and using digital tools to tell patients where they should be getting care.
A pilot project is taking place throughout the city of Shanghai to design a common data set. The government is forcing every provider at every encounter to submit the data. “I’m not saying it’s good, but it’s efficient,” Halamka said. The pilot gives China an opportunity to understand the care experience for 29 million citizens and use that to inform care in the future.
In India, patients own their data, so they can bring their medical records with them to any doctor they visit. The area Halamka visited was very poor, with an average daily income of $1.50, a lack of infrastructure, and a lack of medical care. However, the area had 4G cell phone service.
The Gates Foundation is trying to figure out a way to create a set of services accessible by cell phone so patients and families can input symptoms and find out where to go. Under the plan, every village would have a telemedicine liaison, where families can connect with an expert for a consultation for $1. And maybe, Halamka said, if a system like that can work in poor, rural areas of India, it can work in places such as Massachusetts.
“Sometimes, you actually have to experiment outside the United States to get it right,” Halamka noted.
In the Nordic countries, the technology isn’t the problem; the political circumstances are. Although these countries have decided healthcare for all is a right and that data will be shared across the community, they are now grappling with the General Data Protection Regulation. Norway wants to share genomic information, but how does that kind of information get deidentified?
Finland passed a law declaring that a person’s deidentified medical record belongs to the public because society is keeping that person healthy. “So, how can you deprive society of your life experiences if it could help someone in the future?” Halamka asked.
There is no ability to opt out in Finland because it is the law, and Halamka marveled at trying to get something like this instituted in the United States, where each state has different privacy laws.
In Scotland, every citizen has a problem list, a medication list, last laboratory data, and allergy information in a common database that every emergency doctor in the country can access. “You show up in an emergency department, [and] we already know who you are; we already know what your problems are,” Halamka said. “And we don’t give you unnecessary, unsafe care.”
However, with good ideas, sometimes it’s better “to be a fast follower than an early adopter,” Halamka said, using Australia as an example. Although the country had the good idea to make every medical record available to every patient in a single portal, it made a mistake with the data standard it chose: PDF. As a result, PDFs received by each doctor were making it difficult to perform tasks like drug—drug interaction checks.
In the United States there have been 800 pages of proposed rules to grant every patient full digital access to their clinical and financial data so they will be able to share that information at their will. So far, Halamka said, he is fairly happy with the suggestions that “will make patient care navigation easier for all.”
Halamka was the second patient in the Human Genome Project, which means anyone can look up his genomic data. As someone who participated, he now knows that he has a high likelihood of dying from prostate cancer. Although there have been recommendations to stop prostate-specific antigen (PSA) testing because it is not effective in the overall population, Halamka is not the overall population. In contrast, he is a healthy individual who keeps to a vegan diet, and his cholesterol is low. As a result, it doesn’t make sense to order a low-density lipoprotein cholesterol test for him every year, but it does make sense to order a PSA test every year.
“That’s the kind of care planning you’d like to develop,” he said. But this depends on sharing data, and the country isn’t quite sure how it feels about sharing these data yet.
The collection and use of data also enable the healthcare system to implement artificial intelligence and machine learning. There are some concerns about both because they are only as good as the data being used, and a lot of basic information being collected and input are flawed.
“This is not about replacing doctors,” Halamka said. “It’s about giving doctors the tools to allow them to practice more efficiently and safely.”