Coverage from the Association of Community Cancer Centers’ 44th Annual Meeting & Cancer Center Business Summit, March 14-16, 2018, in Washington, DC.
Surabhi Dangi-Garimella, PhD
Care coordination and integration of multiple care teams are vital to a seamless experience for a patient being treated for cancer. It can help break down silos and allow for a continuum of care, which can, in turn translate into improved outcomes.
At the Association of Community Cancer Centers’ (ACCC) 44th Annual Meeting & Cancer Center Business Summit, March 14-16, 2018, in Washington, DC, panelists discussed the most powerful forces that are reshaping cancer care to be more multidisciplinary.
Thomas Asfeldt, MBA, RN, director, Outpatient Cancer Services, Sanford Cancer Center, joined Robin Hearne, RN, MS, director, Cancer Services, The Outer Banks Hospital; Kavita Patel, MD, MS, FACP, nonresident senior fellow, Brookings Institution; and outgoing president of ACCC Mark S. Soberman, MD, MBA, FACS, Monocacy Health Partners, on this panel.
“Cancer care continues to get complex,” Soberman said. He said that cancer care was already at a point where patients and primary care physicians (PCPs) needed help to deliver the care, and “care teams keep getting complicated.” However, he noted that care coordination is typically not reimbursed, neither are psychosocial care or social work services. “How do we develop platforms that can do all this while ensuring that the patient remains at the center?” Soberman asked.
In his opinion, community-based providers need to collaborate among themselves, as well as with health systems, to better coordinate their patient’s care and provide them with options. An important consideration, in Soberman’s opinion, is “How do we assign responsibility for survivorship care? Does it require training the PCPs?”
Asfeldt has helped build Sanford Cancer Center’s cancer program from the ground up. He informed the audience on the struggles, the changes, and the outcomes that he has witnessed along the way. He particularly highlighted their cancer extenders program, which stemmed out of a grant from ACCC and the BMS Foundation.
“We are currently testing the Oncology Care Collaborative Model at 7 sites,” Asfeldt said. “The program was developed from an assessment tool for optimal care coordination. Oncology care includes a team of researchers, radiation oncologists, medical oncologists, pharmacists, nurse practitioners,” along with others. “Therefore, integrating [the services of these providers] is important.”
At Sanford, champions and commitment among team members are important to help ensure care integration, Asfeldt said. The champion does not necessarily need to be a physician, he emphasized—it can be a nurse navigator, a clinical pathologist, a social worker, or a dietitian. “If someone is not a natural champion, you can try to nurture them, because without a champion, such programs cannot fly,” he added.
Providing a contrast perspective for a smaller, more rural practice, Hearne presented a case study of a program to advocate a prospective peer review for radiation oncology treatments, “Which is difficult for rural [health] systems like ours.”
“Our radiation oncologist championed a project for prospective peer review across our region and he brought in experts from the various centers to develop a standard framework for care,” she said. The peer review group emphasized the importance of evidence-based guidelines, and developed metrics to measure the impact of implementing the process over time. “This was then turned into a scoring tool. We achieved 100% prospective peer review over a period of 1 year and documented a reduction in treatment variability, and better outcomes,” Hearne said.
How do you find the resources for this? Patel asked.
“We can bucket resources,” Soberman said, “such as for people (navigators, coordinators, information technology, etc), technology resources (platforms needed to communicate, data, etc), or site of care.” Additionally, if there are prospects for collaborations or affiliations with other practices or health systems, it presents opportunities for outside resources, he added.
Motivation can be a big driver, Asfeldt said, adding that the scaling up is not a big concern for an integrated cancer care team. There also needs to be clarity around the depth of services that a cancer care team can provide in-house and which services would require either collaboration with another practice or a referral.
Resource allocation decisions require evidence-based guidance on what adds value to the care and services. “We need to make sure our upper management understand the appropriate value of the cancer service line,” Asfeldt said, which will assist with informed decisions.
He also highlighted the importance of philanthropy as an important funding resource. “Philanthropy should be an active part of your revenue stream. One of our other goals is to get 25% of our revenue from areas that are not taking care of sick people, which includes offering weight management programs, licensing on innovation, and commercial real estate.” Sanford Health System’s CEO has been emphasizing this avenue as a resource stream across their health system.
Surabhi Dangi-Garimella, PhD
Improving patient outcomes, ensuring the cost of care remains in check, and not losing site of the patient at the center of it all—healthcare can be tough. And this transition to value-based care requires innovative approaches to care delivery by all involved.
At the Association of Community Cancer Center’s 44th Annual Meeting & Cancer Center Business Summit, March 14-16, 2018, in Washington, DC, payer and physician representatives shared the stage with the president of a cancer foundation that is striving to break the barriers that prevent easy healthcare information exchange and access to cancer care. Participants included Roy A. Beveridge, MD, chief medical officer, Humana; Barbara McAneny, MD, FASCO, MACP, president, American Medical Association (AMA); Anand Shah, MD, MPH, chief medical officer, Center for Medicare and Medicaid Innovation (CMMI); and Greg Simon, JD, president, Biden Cancer Initiative. Harlan Levine, MD, City of Hope moderated the discussion.
Levine asked the panelists to provide context to the audience, asking them, “Why are you on this panel?” on innovation in cancer care delivery.
McAneny said that AMA is working to create tools that would make things easier for physicians. “We are designing the workflow that physicians use to be the center piece. There’s a tremendous influx of data and we do not want to drown in it, but use it smartly,” McAneny said. She added that interopera- bility is a buzz word, but doctors want all the information on wherever their patients have been treated. “AMA has taken this up by setting a consortium to sort and transfer patient information within sites of care,” she added.
McAneny then moved on to discuss the influence of social determinants of health (SDH) on patient outcomes and cost of healthcare. There has been growing realization, not just among health policy researchers who have been studying this for a while, but also among providers that environmental factors and where we stay have a big influence on our treatment outcomes.
“SDH is also high on our agenda. We are not measured based on a patient’s zip code,” McAneny said, but efforts are underway to develop measures, and a code, that account for SDH. “We need to level the playing field, to accounting for disparities,” McAneny added.
Payers recognize the influence of interoperability on efficiency, according to Beveridge. “The inability to exchange data is profound...we have been working with CMS to figure out ways to break data exclusivity and improve sharing [among stakeholders],” he said. He agreed with McAneny on the influence of SDH on not just outcomes, but also the cost of care. “In patients with malignancies, cost of care ranges about 2-6 times higher [among patients who face social challenges],” Beveridge said.
For Simon and his team at the Biden Cancer Initiative, interoperability is incredibly important. “We need to develop data-sharing models, launch virtual clinical trials, and we should conduct trials where people are,” Simon emphasized. He also underscored the importance of cross-pollinating innovative care models between health systems and community-based practices. “How can we let big cities know what’s happening in the community? We need to work toward creating standardized systems, and connectivity is key,” Simon said.
“CMMI is constantly trying to test new models and services, which can potentially reduce burden, because they require scale and the burden could potentially lead to consolidation. My role [at CMMI] is to make the system more accessible, affordable, and multi-stakeholder—driven for care providers,” Shah said.
Surabhi Dangi-Garimella, PhD
What are the biggest drivers of change in oncology care and what needs most attention? This was the crux of the discussion during an early panel at the Association of Community Cancer Centers’ (ACCC) 44th Annual Meeting & Cancer Center Business Summit, held March 14-16, 2018, in Washington, DC.
Deirdre Saulet, PhD, practice manager, Advisory Board, led the discussion by introducing findings from the 2017 Trending Now in Cancer Care Survey, which was developed through a partnership among ACCC, the Oncology Roundtable, and the Advisory Board. Saulet was joined on the panel by Jo Duszkiewicz, MSA, vice president and administrator, Renown Health Institute for Cancer; and Mark Liu, director of strategic initiatives, Mount Sinai Health System.
There were several key takeaways from the survey, which had a majority of respondents from nonteaching community hospitals, followed by teaching hospitals and academic medical centers:
Saulet then invited Duszkiewicz to share how Renown Health Institute for Cancer has adapted to the changes.
Renown’s health system is a combination of acute care, transitional care, network services, and insurance services, Duszkiewicz said.
“Understanding where patients are, where they got their treatment, drawing out specifics of treatment into EPIC, and then ensuring we have all the information is difficult,” she explained. It is further complicated by the fact that Renown works with many rural community practices, which may be 200 to 300 miles away.
“We do practice oncology telemedicine for a few of our communities, in parallel with medical oncologists conducting site visits,” Duszkiewicz said. “We also link with primary care in those areas. However, we found out that primary care physicians were struggling with diagnosis and the tests that were needed.” Consequently, these struggles resulted in an extended time to diagnosis.
To unscramble this situation, Renown developed a solution: the intake oncology coordinator (IOC) process, which included conducting a phone triage first, then a chart review, and finally, bringing the patient in for a clinic visit.
“On evaluating the data, we see that 31% of patients get phone advice, and 25% do a chart review, but 44% of patients who are referred come to see the advance practice nurse,” Duszkiewicz said, adding that IOC has resulted in a very successful clinic.
Duszkiewicz then presented trends within the fee-for-service reimbursement model from 2013 to 2022, which show that productivity adjustments have been increasing, from $4 billion to $94 billion, she said. The shift now is toward value-based contracts, such as the Oncology Care Model (OCM), alternate payment models, and others.
However, Duszkiewicz asked, are shared savings feasible in oncology? She shared data from the Miami Cancer Institute on the results of adopting a value-based approach to care:
She explained that clinical pathway adherence had a significant impact on the savings seen over the first to the third year. However, the diminishing returns of savings in year 4 have triggered more cost savings initiatives within the institute that are focused specifically on the inpatient population.
Next, Liu spoke of Mount Sinai’s practice changes. To be able to provide high-value care and broaden patient access, the hospital has developed several projects and programs, including creating disease management teams (DMTs), building clinical pathways programs, establishing a chemo council, and using Epic Beacon to monitor the clinical pathways being used.
DMTs, Liu said, are focused on quality metrics, value-based care, care pathways, tumor boards, and clinical trials. They are also tasked with narrowing down the quality metrics to avoid overlap and integrating OCM quality metrics with disease-specific metrics for tracking and decision making.
Saulet then spoke about the changing dynamic between the patient and the provider. “Cancer patients are acting independently and asking questions,” she said. “Patients are taking more responsibility for their healthcare costs. Patients have information available at hand on sites of care as well as drugs and treatment. Plus, the patient—provider relation is changing—there are rising expectations on service, with patients feeling more empowered and being skeptical about the care they receive.”
Saulet said that patients with cancer are doing their research: 25% of patients who were surveyed said that they are spending an hour on average reviewing oncologists and 41% said they had researched their treatment options.
Precision medicine is also evolving rapidly, Saulet said, with 92% conducting predictive tests, 92% conducting single-gene tests, 72% conducting small panel tests, and 31% conducting whole-genome sequencing.