Adopting Goals of Care Discussions in Oncology Care Models

As quality-of-life discussions become increasingly mainstream in cancer care, patients and physicians are embracing palliative care in their treatment plans. There seems an increasing acceptance, by both patients and providers, to bring advanced care planning into their conversation to achieve the patient’s goals of care.

The panel discussion, “Tackling Advanced Care Planning in Payment Reform: People and Politics” at the 2015 Community Oncology Conference, included a provider who is an active proponent of advanced care planning (ACP), a program director at a nonprofit health insurance company, and a healthcare consultant, who until recently worked for a big health plan. The panelists were: Kashyap Patel, MD, president, South Carolina Oncology Society, and CEO, Carolina Blood and Cancer Care, who has written an opinion piece for the April issue of Evidence-Based Oncology; Bruce Smith, MD, executive medical director of Government Programs at Regence BlueShield in Seattle, WA; and Laura Long, MD, MPH; retired chief medical officer, Blue Cross Blue Shield South Carolina (BCBSSC), and president of The Long View. The panel was moderated by Patrick Cobb, MD, managing partner of St. Vincent Frontier Cancer Center, Billings, MT.

Dr Smith informed the audience that his clinical life prior to Regence was with a palliative care program. He said that the year prior to his joining Regence, the company’s CEO wanted to see changes in medical benefits design that’d accommodate and pay for goals of care discussions. “We decided to include the benefit, which CMS has had trouble with [death panels] into our health plan benefits. We are actively incorporating goals of care discussions in our plan and our Oncology Care Home model can help develop the metrics for this,” he added.

Emphasizing that non-physicians as well as physicians need to be a part of the goals of care discussion, Dr Smith said that Regence will cover for it. He warned, however, that it’s a process, an ongoing conversation that evolves as people’s views evolve over time, and not just a check box to be marked. He added that the physician groups that their company is working with are happy to see this and its working well for them. Additionally, Regence provides palliative care specialty training for managers and care givers of patients with serious illnesses to help the process, he added.

Dr Long said that her consulting firm is focused on care delivery transformation that can help align incentives. “The last year of my work at [BCBCSC], I worked with 4 oncology practices. Oncology healthcare needs a global perspective so we look at how the whole system works and we also need to personalize it for each practice.”

It’s the same with ACP, she said. “Patient’s desires and values change over time and with their experience of disease and treatment. While hospice has a great value, it’s only a part of the solution.” According to Dr Long, we need to figure a way to initiate conversation at the beginning of care delivery, right when a patient is diagnosed with cancer. She hopes to see ACP become a major part of the discussion on care delivery reform and payment reform, adding that supportive care is needed all through disease progression—it just differs based on the stage of disease, and the patient’s concerns or values need to be heard during the process. She emphasized, “We need to have metrics of implementing this supportive care so payers have proof of a reduction of cost of care or benefits of providing this supportive care.”

Dr Patel, an active proponent of palliative care, said, “We need to make people understand that there will be terminal illness. What can we do about it? We have created unrealistic expectations about death; then we have politicians who like to spin things out of control, like the death panel debate.” Physicians can definitely help the process, he said, by getting trained in ACP and palliative care or end-of-life care. What the goals of care discussion does is it helps making change of care decisions easier as the patient’s disease progresses, he added.