Immunotherapy in the Oncology Care Model - Episode 6
Bruce Feinberg, DO: So we’re starting to get into some of the downside. But before we do that, I think there are some upsides to the program. There are some transformational elements, and you led that off in your first comments. But, go back to that. Kavita, in terms of what our history has been in fee-for-service, and what the OCM [Oncology Care Model] did as a breakthrough concept, what are the top 3?
Kavita K. Patel, MD, MS: Number 1, it’s pretty broad, care coordination. I’ll break that down in statistics a little bit. A great example is the fact that because all the practices had to adhere to something that the Institute of Medicine [IOM] put out, which were really not meant to be, the IOM just said, “Here’s our best guidance.” CMMI [Center for Medicare and Medicaid Innovation] said we’re going to make that part of a payment model, which is very unusual. But care coordination was a huge point of emphasis, including the ability to have somebody on staff or in the office as a resource around financial cost and being able to talk to patients about cost. I think Rich mentioned integration of palliative care. That’s been an aspect of care coordination where end-of-life planning or advance care planning has been a high priority.
A second priority has been this data. The actual use of the data for having care navigators who understand which patients they should reach out to more proactively is an amazing benefit. To your question, Bruce, just pure fee-for-service, which is what I’ve been traditionally practicing in, there are really very few incentives that kind of let you do that. There’s a little bit, but the uptake of some of the programs that exist in fee-for-service has been less than 10%. This is now telling all these cancer doctors that this must become part of what they’re doing.
The third is the comment I made about how people with cancer should see other doctors. One of the requirements in the Oncology Care Model is to actually do a feedback loop where if a cancer patient is seeing another doctor, that the cancer practice—the doctor that’s delivering that care—is responsible for understanding what is happening in the other doctors’ environment. If you talk to regular people on the street, they assume doctors have been doing that since the dawn of time. What’s shocking is that even I, embarrassingly, as a doctor, just don’t do that as part of my work.
Bruce Feinberg, DO: There’s nothing worse than an oncologist being confronted by a primary care doctor who says they ran into their patient’s family member in the Kroger, and they didn’t know they had died, or they didn’t know that they were in the ICU [intensive care unit]. Or they didn’t know when it happened, or that they had relapsed. You feel terrible. I wrote a note. Three months ago, I think I wrote that note. I don’t know why you didn’t get it. But there are those realities, right?
Ted Okon, MBA: I would like to say 1 other thing I think is patient-centric. I have seen practices transform from, and all due respect to the 3 physicians on the panel here, especially the 2 oncologists, the doctor being the queen bee. Everybody buzzes around the doctor. Every nurse, every ancillary person, every PA [physician assistant], nurse practitioner—they all buzz around the doctor, including the patient. I have seen practices transform in terms of where the patient is at the center, and what they’ve had to do is 24x7. You don’t call up and get the answering service in the middle of the night or get thrown to the hospital in the [emergency department] to basically get hydrated on the weekend. They have really listened to the patient. They have done some of the things that I know Susan can talk about in terms of the education of the patient. The patient has become more important, but maybe not as important yet. We have further to go than the physician, but basically the patient has been centric. I think that if you look at the OCM, and if you think of the Oncology Care Model, it’s a medical home, and practices really have transformed. They have transformed into being patient-centric and literally a medical home.
Richard D. Carvajal, MD: As an oncologist, I can say, the patient is absolutely at the center, even if people are buzzing around the wrong person. In terms of the patient satisfaction quality of life, it’s a little bit in the abstract, particularly with the presence of the navigators. We’re not capturing that adequately, but I can tell you, that has made a major impact.
Bruce Feinberg, DO: Something that’s palpable that you can feel is different in your practice.
Richard D. Carvajal, MD: Yes, that’s absolutely true.
Bruce Feinberg, DO: Over the few years of transition.
Kavita K. Patel, MD, MS: Don’t you think it’s happier to practice in that environment? I mean I would almost say that I know nobody feels sorry for me when I tell them doctors are burned out. But, it does feel like the navigators and just the environment of supportiveness actually is helping. I hear physicians say it’s helping them, too.
Richard D. Carvajal, MD: The fact is to deliver the quality of cancer care that we want to, you need a lot of support, and many of us don’t have that. These added services really are significant.
Bruce Feinberg, DO: Rich, when I talk to doctors along the same line, what they tell me has changed their practice in that way has been immunotherapy [IO]. We’re going to get to that in a bit. But when you walk into a waiting room—people aren’t throwing up, they all have their hair, they look happy and well, and they’re being treated for things like lung cancer—that’s what’s changed practices more than anything else. I know that in your world of melanoma, clearly that’s been a huge change.
Richard D. Carvajal, MD: It’s been unbelievable.
Bruce Feinberg, DO: I mean nothing like seeing patients who are all on interferon versus patients who are on IO.
Richard D. Carvajal, MD: I have to say when I started treating melanoma 10 years ago, our goal for patients with metastatic disease was always palliation, quality of life. It was never cure. Since 2011, with these new drugs, we see patients with brain metastases and so forth, and the goal is cure. That’s amazing to be able to actually say that to a patient.
Bruce Feinberg, DO: So my point being, and we’re going to get more in depth into, how that is such a dynamic process. We’re probably in the most dynamic industry, if we’re going to call it an industry. When you look at all those changes, it’s not the same landscape. We put that in, but we have this change in landscape.