WASHINGTON ― With the cost of cancer care continuing to skyrocket and alternative payment models looming, oncology practices are feeling more pressed to deliver patient-centered, value-based care, but the tools to help them do that are still imperfect.
That's the conclusion of representatives from several oncology organizations, who discussed value-based care here at the Association of Community Cancer Centers (ACCC) 43rd annual meeting.
In part, it means rethinking and implementing shared decision making with patients, determining the total cost of care, being able to compare the cost-effectiveness and value of various treatments, having staff to conduct financial counseling with patients, and overhauling information technology so that the process of providing value-based care is seamless.
A 2016 ACCC survey of oncology practice administrators, nurses, pharmacists, and medical directors found that practices are a ways off from being able to offer a value-based experience. Ninety percent of respondents said their cancer program shared treatment recommendations from multidisciplinary meetings with patients and families, and 70% said the program ensured that cost of care is part of shared decision making.
But most programs are still not offering the financial education that patients seek, according to the survey. Thirty-nine percent of programs said that financial advocates meet with all patients to discuss insurance options and cost of care; a similar percentage said advocates meet with all patients to discuss co-pays and patient responsibilities. Only 26% said all patients are given an estimate of cost of care.
What Is Value?
Cost is a crucial component of the value formula, but it's not the only one, said Robert Carlson, MD, CEO of the National Comprehensive Cancer Network (NCCN). That does not mean cost was not considered as the NCCN developed its value-based pathways.
"We realized that while our panels don't use costs in order to put a regimen on a guideline or not, in fact, the reality is, in clinic today, we are all forced to talk about dollar cost," said Dr Carlson.
The NCCN started its quest to add value to its guidelines by consulting the dictionary, said Dr Carlson. "If you go to the dictionary, depending on which one you use, you may find there are 13 to 25 or so definitions of what value actually means," he said.
Value could be transactional — that is, how much it costs to add a year of survival. Or it could be nontransactional — such as the value of being able to keep a breast, said Dr Carlson. Also, individuals vary in what they value, he noted. An 85-year-old may desire a less toxic therapy more than extended survival, whereas a young mother might put more stock in a treatment that adds years.
"We wanted a value system, as we developed it, that was flexible," said Dr Carlson.
The NCCN's members considered efficacy, safety, strength of data, and consistency of data in developing the new pathways. And because cost is a concern, affordability was also added, Dr Carlson said. That metric has provoked a lot of questions. It covers an entire episode of care and includes acquisition and administration costs, toxicity monitoring and management, and the likelihood of hospitalization.
Scores are given for each metric and are then tabulated in a user-friendly chart. "We look at these evidence blocks really as a conversation starter, not an answer," Dr Carlson said. "It allows the physician or healthcare provider to then work with the patient to understand what their value system is, and based upon that, what are the options they should consider," he said.
Facing Financial Toxicity
The American Society of Clinical Oncology (ASCO) built its own Value Framework"to support informed shared decision making between a physician and a patient," said Stephen Grubbs, MD, senior director of clinical affairs at the society.
The conversation should be "about what is the potential financial toxicity that you can be exposed to, and if you're going to do it, what's the benefit you get for the amount of money it's going to cost you," said Dr Grubbs.
The framework, which was updated in May 2016, only evaluates pharmaceuticals; other interventions are not yet included. It defines value as a combination of clinical benefit, side effects, and improvement in patient symptoms or quality of life in the context of cost. The tool gives clinicians a "net health benefit" of a therapy.
ASCO aims to improve the framework's methodology in 2017. For now, the tool can only evaluate treatments that were studied head-to-head in prospective, randomized clinical trials. The organization is working to include cross-trial comparisons, said Dr Grubbs. "Until we have that, there's going to be limited benefit to this," he said.
ASCO will also work to define what constitutes a good net health benefit score and to identify endpoints that are most important to patients.
Even after a few years of work, the Value Framework "is not ready for prime time use by anybody," said Dr Grubbs.
Implementing the OCM
Some 200 physician group practices have already been testing out value-based care through the Oncology Care Model (OCM), launched in July 2016 by the Centers for Medicare & Medicaid Services' Center for Medicare and Medicaid Innovation.
Lancaster General Health, in Pennsylvania, has been participating — a feat that Nikolas Buescher, executive director of cancer services, said he did not think was possible a few years ago, even though the hospital was part of Medicare's shared savings program.
Buescher first presented the idea of enacting the OCM to Beth Horenkamp, MD, the managing physician for the 30-oncologist practice, who wanted to give it her own stamp of approval — a crucial step, because "there's no way to engage physicians unless you don't think it's worth doing," Dr Horenkamp said.
She took the list of requirements for the OCM and condensed it into three topics: improving patient engagement, documenting that you are going by evidence-based standards, and documenting delivery of care in the lowest cost setting, said Dr Horenkamp. "This is something that you can sell to your physicians," she said.
How to do it was the next step. Dr Horenkamp said the hospital had been requiring physicians to collect quality improvement data since 2010, which was an advantage. She also knew that asking physicians to do all the work would not fly. "We tried to divide up the work," said Dr Horenkamp. Each manager was asked to pick at least one person from their group who would feel comfortable in collaborating on various aspects of the OCM.
The OCM project team included information technology staff, schedulers, physicians, nurse educators, data analysts, office managers, medical assistants, and nurses from the clinic, infusion, and radiation therapy units. The group started meeting weekly in 2015 and now meets every 2 weeks.
Everyone has been helpful, she said. "One of our biggest breakthroughs that we had when we were trying to go through shared decision making actually came from one our schedulers," said Dr Horenkamp. That scheduler came up with a simple way to guide patients — after the group had consulted the literature and discussed multiple different examples.
An initial project was figuring out how to match patients to their physician in the electronic medical record (EMR). "We had pizza parties for our schedulers" and had them work overtime to get that documentation piece, said Dr Horenkamp. Now 97% of the patients are tagged with their provider in the EMR, she said.
A lot of the OCM measures concern end of life, but most clinicians don't know what happens to patients in the last few weeks, making it hard to report, said Dr Horenkamp. The group determined a better way to document a date of death — culling names from hospitals and hospices and creating a list that goes back to the clinicians and other providers.
Each physician gets a report every week that shows how his or her care team is doing on various measures for each patient, such as whether staging has been completed, if the Institute of Medicine Care Plan has been finished, and whether advance care planning has been discussed and documented. Each measure is blocked out in red if it is incomplete or green if it is complete.
Dr Horenkamp said no one likes to see red in their reports.
To make the OCM work requires full support of the information technology staff, she said. "If you can't prove that you're doing it, it's not going to matter," said Dr Horenkamp.
Another lesson learned: "You are never done," she said. All the evidence-based pathways that have been completed require regular updating and maintenance.
She said that to make the model sustainable requires "not just checking boxes but taking the time to do something meaningful with the changes they are asking us to make."
Dr Horenkamp believes that value-based payment is how oncologists "are going to get paid in the future," but irrespective of whether clinicians get paid for these changes, "it's something that's actually helping the patients."
The practice is not able to report any data yet, said Buescher. Performance reports for the period July 1 to December 31, 2016, will become available in September 2017, he said.
Dr Carlson, Dr Grubbs, and Dr Horenkamp have disclosed no relevant financial relationships.