Andrew L. Pecora, MD, CPE: I have never had a patient—not once, not ever—come into my room and tell me they want to die more cost effectively. Not once. And yet, we know that the whole idea of survivorship is not just [about] how do you survive your cancer, but when you’re not going to survive your cancer, how do you live the remainder of your life? So, I put a bigger circle around survivorship.
As we move away from “try every last thing to every last moment” and we get into precision medicine, one of the benefits of precision medicine is to know when to stop sooner. Then, the other benefit is that there are things you can do, as time goes on, where you can prevent second cancers and recurrences. So, for this whole concept of survivorship, do you believe that the current models have spent enough time thinking about survivorship and end-of-life care? I kind of put those 2 things together. Or do you think there’s room for improvement?
Brenton Fargnoli, MD: I think the current alternative payment models largely focus, in oncology, on patients on active treatment. [They] would exclude a large portion of those patients, in terms of long-term survivorship, and that would leave just those patients toward end-of-life in your survivorship model. I really like what you said about precision medicine, and to take that and analogize it would be that for really successful survivorship, we need precision goals of care—so that “N-of-1” problem, that patient. What do they specifically want out of their care? They don’t say, “I want the most cost-effective care,” but they might have strong feelings about “I don’t want to die intubated on a ventilator” or “I don’t want to spend my last 30 days at a hospital 2 hours from my family.” [or they may worry about] a feeding tube or these other things.
So, having those discussions takes time. They’re difficult, and they change week to week, month to month. But having a process in place for that, I think, will be really important to cost-effective care. But from the patient’s eyes, it’s having the most effective care for their goals.
Andrew L. Pecora, MD, CPE: Right.
Rena M. Conti, PhD: I agree. I think that survivorship planning and hospice planning are incredibly important. Right now, the focus really is on trying to reduce the variability in what is provided to patients who are, as mentioned, on active treatment. But we’re already seeing providers start to talk a lot more about end-of-life care. I wouldn’t be surprised if the kind of alternative payment model, 2.0 or 3.0, that we ultimately get in a couple of years has a much greater emphasis on—either in terms of stand-alone payments for end-of-life care planning and survivorship planning or quality metrics attached to those, or both—the patient at the center of both their treatment and also their survivorship.
One last thing that I think is really important here is that it’s not just putting patients at the center of long-term consequences of their treatment, but also their financial issues related to their long-term implications of their treatment. I think we’re beginning to see more data about it, and physicians and insurers [need to] be more cognizant of it. The more that patients are at risk for taking responsibility for their cancer care, the more they have to come up with money to pay for stem cell transplants and other types of things that their insurers may not pay the full price of. So, thinking about care planning—that’s not just about long-term patient outcomes, but also the financial consequences of patients for surviving their cancer and now having really big medical bills that they have to deal with. I think this is the future.
Andrew L. Pecora, MD, FACP, CPE: So, this has been a really great discussion. Let’s take a minute and get Dr Sagar to jump back in and give us her perspective.
Bhuvana Sagar, MD: So, do I think that alternative payment models account for survivorship care? Absolutely. Our model does talk about the emphasis on survivorship care. A key component here is that we want the treating oncologist to tie back to the patient’s primary care physician, if there is one. For some patients, we do understand that the oncologist becomes a primary care physician, at least for the duration that they’re taking care of them—especially in advanced stage illnesses.
But we feel that a lot of times, primary care physicians have had a relationship with that patient for a lot longer than the oncologist has. And [many times], they may have a relationship with the whole family. So, the oncologist has to tie it back to the primary care physician, and we’re hoping that they will give them a summary of what treatment the patient had [and] what kind of diagnosis they had. What stage of cancer? What can they expect, and what are the treatments or surveillance strategies that need to be incorporated? Do they need to have scans on a regular basis? Who will be in charge of ordering those scans? So, those are all key questions that need to be incorporated in, and our model definitely does that.