;)
community cancer care: community cancer care
About 700 participants came to Washington, D.C., for the Association of Community Cancer Centers (ACCC) Annual Meeting & Cancer Center Business Summit. At a time of accelerating scientific advances, dramatic changes, and competition in oncology, the meeting focused on new ways of delivering high-quality cancer care to patients in the community.
“The advent of novel therapies, new molecular pathologic identification of cancer diseases, and new disease treatments in cancer is enlarging the care team to include molecular pathologists, interventional oncologists, geriatric oncologists, palliative care providers, and patient supportive care staff such as financial advocates, lay navigators, and home health care providers,” said new 2019-2020 ACCC President Ali McBride, PharmD, MS, BCOP, Clinical Coordinator of Hematology/Oncology at the University of Arizona Cancer Center. “It's clear that to deliver 21st century cancer care, breaking down siloes is not only essential, but salient for the future of patient care.” McBride said his president's theme is “collaborate, educate, compensate: a prescription for sustainable cancer care delivery.”
The meeting encompassed general sessions, breakout sessions, case studies, deep-dive workshops, and an exhibit hall for vendors. Many booths featured new digital solutions to enhance the delivery of care—for example, a software precision medicine decision support tool that synthesizes known data about a cancer patient, recommends the best treatment, provides reimbursement information, and identifies clinical trials, if available.
Oncology Care Innovation
At the meeting, the ACCC's co-host, Foley & Lardner LLP, presented its innovator of the year award to the Center for Medicare & Medicaid Innovation (CMMI), part of the Centers for Medicare & Medicaid Services.
In a general session talk, Amy Bassano, MA, Deputy Director at CMMI, said that most of the center's wide-ranging portfolio of innovative health care payment models, including the chemotherapy episode-based Oncology Care Model (OCM), has been launched in the Medicare program. She noted that CMMI models have touched 18 million Medicare beneficiaries in all 50 states and included 207,000 providers; she cited Accountable Care, Medicare Advantage and Medicare Choices (which provides new hospice options) models as well as the OCM.
“The innovation center portfolio aligns with broader CMS goals,” noted Bassano. These include providing higher quality, more coordinated care at lower cost to Medicare and Medicaid.
Bassano noted that the ongoing OCM payment model includes 192 participating practices, 3,200 participating oncologists, 14 participating payers, and 155,000 participating Medicare beneficiaries. Building on what has been learned from the OCM, “We definitely want to be working on a new iteration of this model,” she said.
CMMI has a new initiative: request for information (RFI), which seeks ideas on promoting patient-centered care and testing market-driven reforms that empower beneficiaries as consumers, provide price transparency, and increase choices and competition to drive quality and improve outcomes. The CMMI website has a portal that allows visitors to share their own innovative ideas on health care payment and delivery.
For 2019, Bassano said, CMMI is focused on implementation of its models, monitoring and optimization of results, evaluation and scaling, integration of innovation across CMS, portfolio analysis, and the launch of new models to round out its portfolio. She noted that CCMI has done a comprehensive analysis of its models' quality measures to see what they are actually measuring. She noted that CCMI's development process for alternative payment models is not linear and is not necessarily short; it may take a year from announcing a new model to putting it into operation. Under development is a bundled radiation oncology model.
Value-Based Care
In a case-study session on realizing the promise of value-based care and the OCM, two physicians presented data on their experience with the OCM—which has been mostly positive.
“OCM participants are closing the gap between actual and target costs per episode” of chemotherapy, said Charles Saunders, MD, CEO of Integra Connect, a health care technology company focused on helping specialty physicians make the transition to value-based care. Specifically, he noted that Integra Connect data from 60,000 OCM episodes show that savings in the OCM episode-based payment model reflect progress from the initial performance period to the second performance period, with “an average 46 percent decrease in the delta between the actual price and CMS targets.”
Saunders shared that OCM participants in this dataset report the rising cost of drugs, inpatient stays, and emergency room visits as the largest cost drivers of care. He said strategies to keep these costs down include rationalizing drug use (e.g., switching to generics and biosimilars); use of end-of-life resources; reducing adverse events; managing co-morbidities; closing documentation gaps; making optimum use of novel therapies; predictive analytics (e.g., risk-stratifying patients); and leveraging evidence-based care pathways to improve survival rates and reduce costs. Integra Connect surveys show that “community oncologists are optimistic about value-based care,” said Saunders, and a majority expressed interest in alternative payment models beyond the OCM.
“Success under value-based care requires practice transformation,” said Lucio N. Gordon, MD, Managing Physician and President of Florida Cancer Specialists, which treats patients throughout the state of Florida—10 percent of whom are in the OCM.
“As far as educating doctors, this was painful,” he said of adopting the OCM. “Physician engagement was very important.” Gordon named the following as necessary for success with a value-based alternative payment model such as the OCM: physician buy-in, a shift in culture, 24/7 access to physicians, extended hours, weekend hours, patient education, standard operating procedures, care management, and appropriate use of supportive medications.
Gordon said Florida Cancer Specialists' efforts to make the OCM work have paid off. OCM third period results show that overall hospital admission rates were 8.5 percent less for OCM patients than for their non-OCM peers; there were 41 percent fewer emergency room visits among OCM patients; and admission to inpatient short-term acute care stays decreased by 19 percent. Readmission rates were also down. Most important, OCM patients reported an overall satisfaction rating of 9.02 (out of 10). “We have leveraged hospice to improve end-of-life care,” noted Gordon, and this has enhanced cost containment.
Cancer Care Organization
In today's competitive community practice environment, “providers are taking on more risk,” said Deirdre Saulet, PhD, Practice Manager for the Oncology Roundtable of the Advisory Board Company and a general session panelist on organizational imperatives for cancer care delivery. For that reason, she noted, many community cancer practices are seeking security in marketplace consolidation to increase their size.
She cited highlights from the ACCC's “2018 Trending Now in Cancer Care Survey,” showing that while marketplace consolidation slowed somewhat between 2017 and 2018, in 2018 18 percent of respondents said they merged with or acquired a health system or hospital, 14 percent affiliated with a cancer program, and 14 percent merged with or acquired an independent physician practice.
In a session on hospital-oncologist alignment, speakers stressed that business issues can make or break the transition when practicing community oncologists merge with a hospital. Important factors include strategic alignment, trust (or lack of it), the cultural fit, governance, tax structure, financial terms/valuation, treatment of ancillaries, and financial implications for physicians, patients, and payers, said Tena W. Messer, MSN, ANP-C, AOCN, Regional Executive Director of Cancer Care of WNC in Asheville, N.C.
She advised oncologists considering aligning with a hospital “to establish a small team to negotiate meetings, set expectations, and know the market.” She also advised seeking an experienced and strong legal partner. Messer told Oncology Times that one innovative idea she is now exploring is oncology hospitalists—specialty hospitalists who focus on cancer care in the hospital setting.
“The mixing of cultures can be very difficult,” said Erich A. Mounce, MSHA, a Nashville-based Chief Operating Officer for OneOncology, who also participated in this session. “It's very hard to prepare for all the challenges that are going to come up.”
For example, he noted that most hospital administrators are not receptive to research because it does not make money. He advised preparing community oncologists considering aligning with a hospital for what it is actually like to work in the hospital world.
Digital Technology
Some of the sessions at the ACCC meeting focused on innovations in symptom management in community practice. Use of a powerful digital tool can assist nurses in helping cancer patients manage complicated events and avoid emergency room visits, said Mah-Jabeen Soobader, PhD, MPH, Chief Analytics Officer at Archway Health, who presented data from a study published in the Journal of Oncology Practice that analyzed more than 10,000 triage incidents documented at two mid-sized community cancer practices: the Center for Cancer and Blood Disorders in Fort Worth, Texas, and Northwest Medical Specialties in Tacoma, Wash. (2019;15(2):e91-e97).
During the 6 months of the study, on which Soobader was a co-author, there was a 6-7 percent reduction in emergency room events with use of the digital tool due to symptom management using standardized pathways. The authors estimated that the annual number of avoided emergency room events due to triage was 426, which amounts to a savings of $3.85 million for the two practices.
The study concluded that “ER events and associated hospitalizations can be avoided as well as quantified as a result of the deployment of a practice-level integrated platform that incorporates physician-scripted symptom management protocols and telephone triage pathways.”
Immunotherapy Knowledge
One of the ACCC meeting's deep-dive workshops focused on immunotherapy. In 2018, immunotherapy advanced in its importance to cancer care delivery, but the ACCC notes that community practices lag in providing patients with this form of treatment. As previously reported in Oncology Times, the 2018 ACCC trends survey found that 72 percent of respondents reported cost and reimbursement as their biggest challenges in offering immunotherapy to their patients.
A new report from the ACCC's Immuno-Oncology Institute, “Immuno-Oncology: Connecting Science, Policy and Real-World Care Delivery,” stresses the importance of incorporating services and tools into community practices to support cancer patients on immunotherapy. Very specifically, patients on immunotherapy should carry wallet ID cards stating that the patient is being treated for cancer on immunotherapy, listing the warning signs of the most common immune-related adverse events and giving 24/7 contact information for the treating oncology team.
This wallet card is especially useful for immunotherapy patients at the start of treatment, when they are most vulnerable to an emergency room visit, emphasized Junaid Razzak, MBBS, MD, PhD, Professor and Director of Telemedicine, Department of Emergency Medicine at Johns Hopkins University. As a member of the Telemedicine Working Group of ACCC's Immuno-Oncology Institute, he noted that in many hospitals the emergency room staff may have very limited experience with immunotherapy patients and their potential adverse events.
As stated in the new ACCC report on immunotherapy, “Moving forward, immunotherapy is poised to become a dominant pillar in the armamentarium of cancer treatment. Yet it's important to remember that the oncology community is still at the very beginning of this journey.”
Peggy Eastman is a contributing writer.
