The Association of Community Cancer Centers held its 46th Annual Meeting and Cancer Center Business Summit March 4 to 6 in Washington, DC.
Evolution. Disruption. Innovation. Telemedicine. A virtual exchange of information. Healthcare has lagged behind in these aspects, but it is necessary to transcend time and distance, according to Susan Dentzer, senior policy fellow at the Duke-Margolis Center for Health Policy, during her presentation “Disruptive Innovations That Could Change the Delivery of Cancer Care” at the Association of Community Cancer Centers 46th Annual Meeting and Cancer Center Business Summit, held March 4 to 6 in Washington, DC. This is her vision for the future of cancer care.
Dentzer spoke passionately about elevating the quality of cancer care delivery by changing the system and asking these questions:
• How do we take the possibilities that exist and expand them?
• What are the best ways to innovate?
• What if, instead of a sick-care system, we had a healthcare and health-inducing system that went to the people rather than the people going to it?
• Why is this deemed necessary?
Her biggest question of all: for healthcare that mainly involves exchanges of information, not the laying on of hands, why isn’t more of it done virtually today? This is especially pertinent when study results show high levels of patient satisfaction, higher quality of life, less depression, and less stress with telehealth and teleoncology.
According to Dentzer, it is time to think outside the box, incorporating data and technology to elevate cancer care delivery. She provided a telling question from A. Mark Fendrick, MD, coeditor-in-chief of The American Journal of Managed Care®, that illustrates how despite advancements in cancer care, obstacles to optimizing its delivery remain: “Why do we have Star Wars medicine on a Flintstones delivery platform? Shouldn’t we at least advance to The Jetsons?”
What many do not realize is that telemedicine, at least the idea of it, has been around since the late 1960s. During her presentation, Dentzer related how Kenneth D. Bird, MD, a former internist and pulmonary specialist at Massachusetts General Hospital (Mass General), developed the first telemedicine system between Logan Airport and Mass General in 1968, with a second link in 1970.1 However, the system was abandoned in the 1970s.
A common theme that ran throughout her presentation was that it is time for healthcare and cancer care to move outside the conventional walls of practices, to not be afraid of innovation, to move closer to patients where they are in their homes and communities. The quality of cancer care needs to be elevated to such a level that it minimizes the amount of time people have to be in the hospital. But doing so first means addressing several important challenges:
• An estimated 70% of US counties lack an oncologist.2
• There is an uneven distribution of the overall cancer labor force.
• The aging population has an increasing incidence of cancer.
So, what can we do? What are some examples of opportunities to innovate in medicine?
Teleoncology. This has already been shown to improve access to care and decrease costs, Dentzer noted. Also, with oral cancer drugs and immunotherapies being delivered on an outpatient basis in some instances, teleoncology can help by providing remote supervision of chemotherapy, thereby preventing unnecessary trips to the hospital or doctor’s office.
For example, Boston University’s Biomedical Optical Technologies Lab (BOTLab) has developed a wearable probe, now in clinical trials, that uses near-infrared spectroscopy to measure hemoglobin, metabolism, water, and fat levels in tumors. The University of Arizona created its telemedicine program in 1996 and introduced telemammography between rural locations and the university in the early 2000s; women’s images from a remote location are analyzed within 45 minutes at the university. Lastly, in 1995, Kansas University Medical Center instituted its first teleoncology program with a multidisciplinary team that is 250 miles from a rural medical center, which itself has nurses.
Telegenetics. Abramson Cancer Center in Philadelphia, Pennsylvania, offers genetic counseling in real time, which can be accessed over the phone or through video conference. As this is a service that is not always easy to access, especially when patients are hundreds of miles away, making the counseling more portable can only serve to increase access to care.
Symptom management. Because not all patients need to be seen in the clinic, Seattle Cancer Care Alliance provides a web portal through which they can enter symptoms. This sends an alert to their care team and that alert leads to a phone call.
Provider education in immuno-oncology. This is particularly needed for emergency medicine physicians. Telemedicine can increase engagement and communication between experienced oncologists and emergency medicine physicians who may have limited knowledge of immunotherapies and their adverse effects. It also provides opportunities for online learning and 24/7 access to critical care information.
Access to clinical trials. Denzter pointed out that almost 8 of 10 clinical trials can be delayed, even closed, because recruitment takes too long. Telemedicine can remedy this by “expediting patients’ access to clinical trials” through automated platforms.
“I would argue that the status quo is not an option. You need to take advantage of these capabilities really fast,” Dentzer noted.
1. Dr Kenneth Bird, 73; used TV for diagnosis. The New York Times. nytimes.com/1991/02/16/obituaries/dr-kennethbird-73-used-tv-for-diagnosis.html. Published February 16, 1991. Accessed March 25, 2020.
2. Charlton M, Schlichting J, Chioresco C, Ward M, Vikas P. Challenges of rural cancer care in the United States. Oncology (Williston Park). 2015;29(9):633-640.
Before her keynote address, “A Frank Conversation About the State of Healthcare in the United States” during the Association of Community Cancer Centers’ 46th Annual Meeting and Cancer Center Business Summit, held March 4 to 6 in Washington, DC, Senator Debbie Stabenow (D, Michigan), was introduced by Dennis A. Cardoza, cochair of the Federal Public Affairs Practice and chair of the California Public Affairs Practice of Foley & Lardner LLP. He polled the audience with this question: In 2019, healthcare emerged as the top policy issue for Americans. What do you see as the number 1 driving force behind this crisis?
1. Access to services
2. Concerns over the cost of treatment on the individual level, high co-pays, deductibles, etc
3. Concerns over the cost to society as a whole
4. The “broken” healthcare system
5. Concerns over the quality of care being delivered
Stabenow, a member of the Senate Finance Committee and ranking member of its health subcommittee, followed with her perspective on the state of healthcare costs in the United States today, touching upon how each of the above choices affects healthcare affordability. She reinforced the importance of investing in the country, in public infrastructure, and in public health infrastructure, especially where oncology is concerned, because “it’s about hope. It’s about finding a path. It’s about providing life-saving medications.”
She expressed concerns over the Trump administration’s promotion of short-term insurance plans, from a coverage and treatment standpoint, that don’t have to cover people with pre-existing conditions or that don’t provide the basic coverage called for by the Affordable Care Act (ACA). They are “cheap,” she said, and patients don’t know if they are covered until they get sick, whereas under the ACA, preventive care is covered without a copay.
The Congress is trying to figure out how to not go backward, Stabenow noted, especially in the face of President Trump’s proposed $1.6-trillion cut in future healthcare spending, and “we’re going to work very hard to push back.”
One example is by supporting robust efforts for community health centers and certified community behavioral health centers, because “we predominantly treat these areas not as real healthcare, through healthcare reimbursement, but through grants.” Communities deserve structurally sound, high-quality care.
Stabenow also discussed the cost of vaccines and treatments, shining the spotlight on a recent $3-billion investment in research and vaccines that did not include language guaranteeing that if this research produced effective vaccines, they would be affordable when brought to market. “The federal government should use its power to negotiate a price,” she pointed out. “Keeping the quality high is not worth it if at the end Americans can’t afford the medicine.”
Insulin prices have climbed about 15 times in the past number of years, she said, stressing again that Americans must have access to affordable medications.
“For every one of us, healthcare is not political, it’s personal, and we should all be coming together on every issue, on a nonpartisan basis, to do what we can to make things better, to improve access to care, to improve the quality of care, and to reduce costs,” she concluded. “We can have a difference of opinion in how we approach things. That’s how you get to the good decisions. But we need to not start from a political or ideological position, but from the position of how to make things work.”
The theme of the Association of Community Cancer Centers’ immediate past president Ali McBride, PharmD, MS, BPS, BCOP, for his 2019-2020 term was “Collaborate. Educate. Compensate: A Prescription for Sustainable Cancer Care Delivery.” Nowhere was that more evident than in the panel discussion he led on day 2 of this year’s annual conference, which focused on the importance of supporting patients and not just managing the process of their care.
McBride, clinical coordinator, hematology/oncology, Department of Pharmacy, The University of Arizona Cancer Center, was joined on the panel by:
The panel discussed the results of Resource and Reimbursement Barriers to Comprehensive Cancer Care Delivery, an ACCC survey originally piloted at the 2018 and 2019 annual meetings that was meant to gauge barriers to delivering the most effective and comprehensive cancer care. Following the 2019 meeting, 172 ACCC member programs responded to questions that covered 27 supportive oncology services, and this panel touched on 5 of them:
McBride opened the discussion by relating that more than half of the responding oncology practices said they had inadequate resources to provide nutrition, palliative care, financial services, or even genetic counseling. Most offer some supportive oncology services, but these vary in capacity. What they all agreed on, however, was the need for adequate staffing “to deliver supportive oncology services to all patients who need them.”
“We need to create a dissemination strategy to inform policy and oncology reimbursement,” McBride emphasized. “There needs to be sustainable care delivery. How does your organization do this?”
The results? Through the survey, the members of the panel helped develop a tiered, comprehensive cancer care services matrix whose top 5 areas are those mentioned above and explained in further detail below. It addresses such questions as what else is needed to add and/or grow this service and what members of the multidisciplinary team can and/or should provide.
“Navigation is a service, not a job description. Every person a patient comes in contact with has the job of navigating the patient through that part. Navigation is a process that needs to be hardwired into every single member of a team,” McAneny stated.
The panel agreed on the importance of patient navigation being a team effort.
“The idea is that when you meet a patient,” Benson noted, “you can link them with the appropriate person on the team. So start at the very beginning to identify what is important to that patient.”
Cost is also a factor in this area, as there needs to be adequate funds for both the physicians and their patients.
“There needs to be clearly designated time and resources to each team member so they can do their job and it doesn’t become unsustainable over time,” Strawbridge added. “We must recognize the investment in staff and resources and provide rewards in the form of reimbursement.”
Financial Needs Counseling and Navigation
The survey results showed there is a gap between the cost and reimbursement of cancer care services, with out-of-pocket patient payments, grants, and charitable contributions making up the difference. However, often that is still not enough.
“What is the return on investment?” McBride asked.
“Financial toxicity used to not be a thing,” Kirch responded. “We must be amplifying the voices of what patients and their families need.”
McAneny agreed, saying, “Even with Medicare, the out-of-pocket costs are enormous. It costs me $15 to collect the $5 copay. Look at the insurance industry. Stop playing the cost-shifting game. Two-thirds of bankruptcies are triggered by a medical event, and two-thirds of those have insurance.”
The overarching theme during this segment of the panel was that patients and their caregivers need to be heard and understood and that it is every care team member’s responsibility. Patients can be educated on the role of palliative care, and comprehensive community cancer programs can develop and offer referral pathways. Palliative care‹is not a one-time event; it continues throughout the cancer care process. Still, doctors do not want to have these conversations, Strawbridge pointed out.
“Patients with advanced lung cancer live longer with palliative care services,” Oyer noted, “but only 19% are referred. Who needs to be educated? The patients or the system? We need a system that changes.”
Kirch noted the reach of online training in this regard. “We need to train professionals. Start thinking how we can support these services. Everyone is responsible for providing palliative care to patients. Everyone needs to have basic conversations with patients about how treatment can impact lives.”
“Nurses, pharmacists, physicians. It’s everybody’s job,” Smith said. “It’s an ongoing situation, not a fixed event.” Nevidjon agreed, calling for an investigation into “what we are teaching in our education programs.”
Survivorship Care Planning
The panel agreed that survivorship care planning in oncology needs to be a dynamic process. The increasing numbers of survivors, over time, experience a lot of other comorbidities that the oncology community is not prepared to deal with, so primary care needs to be embedded with oncology, stated McAneny.
However, “primary care is in a crisis situation. In primary care, the shortage of providers is worse than in oncology. How do we handle 10 million patients and growing? What will be the long-term outcomes of people getting immunotherapy? This is one component of what we will need to do in the long run,” Benson added.
“Patients groups remind us that they think of survivorship as starting when a patient is diagnosed,” Strawbridge said.
Proposed solutions in the survey include providing a survivorship care plan to every patient and communicating this information to the patient’s primary care physician (PCP). Again, collaboration was the name of the game, especially when working with PCPs on transfers of care and follow-up.
The panelists agreed that the current system needs updating because it is rife with issues. Major changes are needed. Oyer noted that the top 3 issues are staff resources, program infrastructure, and lack of patient understanding of the process, but that a solution is top of mind.
McAneny agreed that the system is flawed. “We need a system that opens trials in under a month. We need trial participants that more reflect the country we serve. It’s a cumbersome and clunky system that desperately needs to be streamlined,” she stated.
“We’re constantly under pressure to make sure our populations include a diverse population. Patients want to be treated in the communities where they feel most comfortable. But those small local hospitals don’t have the resources,” Oyer responded. “We are going to develop a new roadmap on how to find a trial, so we can address the needs of traditionally [underserved] populations in our country.”
“It’s been a learning curve,” McBride concluded.
“We need ways to be better, to be more efficient. Can we predict which patients are at high risk of hospitalization, and how can we reduce this risk?” asked Debra Patt, MD, MPH, MBA, executive vice president of policy and strategy at Texas Oncology; medical director of analytics, McKesson Specialty Health; clinical professor, Dell Medical School, University of Texas at Austin; and editor-in-chief, JCO Clinical Cancer Informatics. “How many of you use clinical decision support systems that are integrated within your electronic health record to make therapy choices at the point of care? There’s an opportunity to do better.”
During her presentation “Applied Informatics in Oncology” at the Association of Community Cancer Centers 46th Annual Meeting and Cancer Center Business Summit, held March 4 to 6 in Washington, DC, Patt detailed Texas Oncology’s experience using clinical informatics to guide treatment practices and decisions, which she believes can increase both the value and quality of care.
Using clinical informatics and decision support can help with guideline adherence, clinical and patient education, and predictive analytics. Having these tools helps to ensure quality by facilitating evidence-based decision making.
This is especially important with the increasing numbers of long-term cancer survivors and the growing complexity of cancer care in regard to more cancer subtypes, treatments, combination therapies, and targeted treatments, especially immunotherapy, Patt pointed out.
Between 1991 and 2016, there was a 27% reduction in the overall cancer death rate, equating to more than 2.6 million lives saved, according to data Patt presented. And from 1971 to 2030, there is estimated to be a more than 7-fold increase—from 3 million to 22.1 million—in total cancer survivors. “This is a totally different field than it was 10 years ago,” Patt said. “When you have complexity, it’s useful to have something like decision support to help you manage the complexity.”
She emphasized that in order to be successful, these integrated solutions need to be patient-centric and help patients and their physicians to make better, more-informed treatment decisions. This can be accomplished through the use of iterative solutions and high-quality pathways that are expert- and outcomes-driven, evidence-based, patient-focused, and comprehensive, and that promote research and continuous quality improvement.
Patt illustrated how clinical decision support tools bolster care delivery, explaining that the shift from volume-based to value-based care that took place under the Oncology Care Model (OCM), which was meant to improve quality and increase service value in oncology care, necessitates their use.
Before the OCM, the care delivery model consisted of a consult, financial counseling if paying out of pocket for treatment, chemotherapy education, treatment start and conclusion, and a survivorship visit, depending on diagnosis, she illustrated. However, with OCM providers required to institute 13-point care plans, the additional information required by the OCM to prove the worth of a service makes applied informatics necessary.
It is all about being more efficient and effective at the point of care, of using that information to improve care delivery.
“The OCM has been a catalyst for a lot of changes in oncology in a system that is changing dramatically. I think the only way we are going to get better is if we share information with each other, with regards to the strength and limitations of what we do. We’ll get there better, faster, and safer,” she concluded.