The health delivery model of integrated multidisciplinary cancer care teams is helping oncologists deal with the challenges of an increasingly complex field with growing numbers of patients, according to speakers at the Annual Meeting & Cancer Center Business Summit of the Association of Community Cancer Centers (ACCC), held in Washington, D.C.
“When we get the right members on the team, we can have providers doing what they love to do,” said ACCC President Mark S. Soberman, MD, MBA, FACS, Medical Director of the Oncology Service Line and Chief Physician Executive of Monocacy Health Partners, Frederick Regional Health System in Maryland. “We've got to make the system more provider-friendly,” he added, so those caring for cancer patients do not feel they are spending too much time “clicking boxes” on a computer screen. Soberman said that, by emphasizing good patient care, the team concept can lead to resilience for providers. “It's relationships, it's people, it's technology.”
“Oncologists can't do it all,” Soberman told Oncology Times, noting that today there are more cancer cases and more survivors. He added that, while some “silos” still exist in community practice, there is a trend toward more integration of multidisciplinary professionals across the cancer care continuum. He noted that professionals other than oncologists can help with data acquisition, tracking down information, and providing survivorship care, among other tasks. In some cases, the oncologist can refer survivors back to their primary care physicians.
The recently released ACCC 2017 survey of community oncology practices shows that the majority use advanced practitioners: 81 percent of practices surveyed use nurse practitioners; 41 percent use physician assistants; and 21 percent use clinical nurse specialists. Only 12 percent do not use advanced practitioners.
In addition to oncologists, pathologists, radiologists, surgeons, nurses, physician assistants, and pharmacists, today's expanding cancer care team may include patient navigators, social workers, dietitians, financial counselors, genetic counselors, and the list continues to grow. Soberman said that, with the use of immunotherapy, some cancer patients may develop side effects from toxicities and need treatment by gastroenterologists, cardiologists, and other specialists.
ACCC Executive Director Christian G. Downs, JD, MHA, noted that attendance at the 2018 annual meeting was “overflowing”—some 1,000 registrants. He attributed the high attendance to the expanding multidisciplinary scope of practitioners on the cancer care team.
“There has never been a better time to be an oncologist,” said Michael Kolodziej, MD, FACP, Vice President and Chief Innovation Officer at ADVI Health LLC, a consulting company. “The explosion of what we can do for our patients is just incredible.”
Speakers shared that the emphasis on “big data” and data sharing has the potential to continue to improve clinical practice through evidence-based care provided by a team. “There's no doubt that we are seeing the benefit of capturing data,” said Brenda Nevidjon, RN, MSN, FAAN, Chief Executive Officer of the Oncology Nursing Society. But, she said there are different responses to the emphasis on acquiring vast amounts of data, which can be daunting. She hears some nurses say, “I am taking care of a computer, not a patient.”
“Clearly there's a lot of work ahead to help big data live up to its promise,” added Bobby Green, MD, MSCE, Senior Vice President of Clinical Oncology at Flatiron Health. He noted that collecting large amounts of data points can be “incredibly burdensome” and recommended strongly that health IT vendors be involved in data acquisition tools earlier in the process of design. He noted they need to consider what user interface would be easiest for the clinician to make data collection easier—including and going beyond the electronic health record (EHR). But overall Green said the design of IT tools is becoming more useful to clinicians: “I see optimism—there's a movement in that direction.”
“For precision medicine to have an impact on cancer care, it's got to work in the community,” stressed Michael V. Seiden, MD, PhD, Senior Vice President and Chief Medical Officer for McKesson Specialty Health and the US Oncology Network. For community oncologists to take advantage of opportunities afforded by big data, he advised them to work as closely as possible with the laboratories they use, have an automatic data feed of relevant information into the EHR, use diagnostic pathways, and rely on an updatable clinical support system.
The growing emphasis on integrated multidisciplinary cancer care teams as a health delivery model has meant an uncertain future for smaller practices, noted Kolodziej. “I actually don't see a universe in which small practices can survive.”
In the future, he foresees large health entities collaborating for mutual benefit. The ACCC 2017 survey noted that marketplace consolidation in cancer care is continuing, with respondents reporting that 21 percent merged with or acquired a health system or hospital, 18 percent affiliated with a cancer program, 16 percent merged with or acquired an independent physician practice, and 16 percent entered into a professional services agreement or co-management agreement. Some 49 percent reported they were satisfied with these mergers, while 21 percent said they were very satisfied.
Health Care Strategies
In a session on hospital and physician alignment strategies, speakers discussed the advantages of converting physician office-based practices into hospital outpatient licensed facilities, among other topics. On the plus side, physicians are paid more in such an arrangement, said Michael L. Blau, JD, an attorney with Foley & Lardner LLP in Boston. He noted that, under the Tax Cuts and Jobs Act of 2017, which repeals the individual health insurance mandate under the Affordable Care Act, there is likely to be a reexamination of alignment strategies because hospital-aligned physicians may have to absorb some uncompensated care for uninsured patients.
Asked by Oncology Times if the new tax act is likely to have a chilling effect on hospital alignments for physicians, Blau said, “These deals will proceed apace.” But, he noted, physicians in aligned relationships may have to assume more risk because hospitals will expect these physicians to treat all comers, including uninsured patients.
As the integrated team approach to cancer care has evolved, so have new models of patient-centered, value-based care. In 2016, the Centers for Medicare & Medicaid Services launched the 5-year Oncology Care Model (OCM), a multi-payer model focused on providing higher-quality, more-coordinated cancer care. The model focuses on physician financial and performance accountability for episodes of care surrounding the administration of chemotherapy. The ACCC has initiated the Optimal Care Coordination Model (OCCM) in which seven ACCC member programs are serving as testing sites. According to Soberman, these sites are deploying the OCCM model to conduct quality improvement efforts, with the goal of improving access and care coordination for lung cancer patients on Medicaid.
“Different sites have different resources and challenges, but all are striving to deliver patient-centered care and improve outcomes for a specific patient population. Improved outcomes will create value for patients,” wrote Soberman in the January-February 2018 issue of Oncology Issues, an ACCC member publication.
In a meeting session looking to the future of cancer care payment, speakers discussed reimbursement via commercial pricing bundles in oncology, in which a practice would be paid one overall fee for managing all the associated costs of a cancer case. When it comes to bundling, cancer is tricky, said Stuart Goldberg, MD, Chief Medical Officer at COTA Inc., a real-world data analytics company, and Associate Clinical Professor of Medicine at Rutgers: the New Jersey Medical School. “If you don't stratify your patients right, you can lose in bundles,” he cautioned. Compared to a knee replacement, for example, reimbursement for a breast cancer patient is far more complicated, and thus one payment model for breast cancer is too broad. What stage is the patient's cancer? Is there an actionable mutation? How expensive will the patient's drugs be? What about toxicities? Are there likely to be hospital readmissions?
Goldberg said that, although bundled pricing is much more complex in oncology, it can be done. He said COTA has developed a disease classification system, the COTA Nodal Address, which facilitates bundled care design. The coding system organizes the complexities of patients and their diseases in a precise form that permits detailed analyses of outcomes, toxicities, care variances, practice patterns, and cost. “What we want to do in bundles is reduce the variance” in patient care, said Goldberg, noting that some phenotypes are treated the same while others have great variances in care. “Understanding the variances is key,” he said.
The goal is to group like patients together, said Lili Brillstein, MPH, Director of the Episodes of Care Initiative at Horizon Blue Cross Blue Shield of New Jersey. “We're all at the beginning where we're trying to unstick ourselves from fee-for-service,” she noted. “These models are very different from fee-for-service; these are fee-for-value.” The Episodes of Care Initiative at Horizon uses the COTA tool to organize patients into clinically like categories with clinically like outcomes, which should potentially reduce variations in care. “Everyone needs to be very collaborative” in a bundled payment system, said Brillstein. “The focus is on outcomes, not on incremental care.”
Brillstein advised administrators of cancer programs to approach bundled payment systems slowly. “I would caution you from going right from fee-for-service into risk-based models.” But, she noted that, if the structure is right and the money is right, bundled payment models should work well—especially since they are managed by physicians with no need for pre-authorization. She explained that with good management there might even be money in the bundled payment for services that could be important to the patient's quality of life, such as transportation fees for medical appointments, yoga, or massages.
Peggy Eastman is a contributing writer.