Cancer Care Plans Within ACOs Must Center Patients First: Dr Leslie Busby

Leslie Busby, MD, board-certified medical oncologist and hematologist at Rocky Mountain Cancer Centers and chairman of the US Oncology Network Pharmacy & Therapeutics Committee, discusses the process of developing patient-centered care plans within the framework of an accountable care organization (ACO) and the importance of staying up-to date with the latest best practices and therapies.

Transcript

Can you describe the process of developing patient-centered cancer care plans within the ACO framework?

Whatever plan you have, you definitely have to put the patient at the center of anything. So when we're talking about choosing regimens that might be best, we start off by which regimens are most active and which have the best data to support their use, and then we also look into the toxicity. So any sort of program or anything that we're looking at, the first step is, how will this affect the patient? Patients don't want to go in the hospital, so if we look at, "OK, how do we keep patients out of the hospital?" then we go from there. It's always the clinical aspect first, before you walk into any sort of decision or strategy behind it.

What measures are in place to help ensure that patients receive the most up-to-date, evidence-based cancer treatments and therapies while still controlling costs?

We rely a lot on the US Oncology pathways. The pathways task force is a subcommittee of the [Pharmacy & Therapeutics] Committee, and we have several members of Rocky Mountain Cancer Centers as part of that committee or as part of disease specialist advisors to that committee. They meet monthly, always overlooking the pathways—do they need to be updated—and also staying ahead of new information coming out, whether from a major meeting such as ASCO [American Society of Clinical Oncology] and ASH [American Society of Hematology] or just new papers that are coming out. We also have a system set up that any regimen that goes on our pathway must be an NCCN [National Comprehensive Cancer Network]–based regimen first.

While NCCN has a little bit of a different way of looking at things, they're sort of taking the totality, the whole universe of regimens out there, and paring them down to those that really have decent support. And then we're paring it down a little bit further, which fits our our strategy of "good product, controls toxicity, and is lower cost." I think you have to meet often. There are groups out there that have pathways, and they fall behind really fast, and it makes it a challenge to perform on their pathways when they're not keeping up to date.

Are there any oncology quality measures in particular that have been challenging to improve upon in an ACO?

I think what I struggle with, and looking at the numbers, [they] are around advanced care planning and hospice care. When I when I look at, I think there's 2 issues that we have struggled to get by—all of us. One is as oncologists, we go in with the mindset of wanting to treat patients, wanting to try to control their cancer. So it is a little bit different. You have to think a little bit differently when it comes to advanced care planning and hospice. The other side is that there's a lot of patients who just aren't ready for it. We need to find that sweet spot in the middle where we can still bring it up and talk to the patients without them shutting down, but we at least start opening the door. And still looking for that best approach—even though I've been practicing over 20 years—in my own day-to-day approach, and what works best for each patient. But that is a metric that I feel like we've improved, but not as much as I'd hoped.

What challenges or barriers impact the delivery of high-quality cancer care in an ACO, and how have these challenges been addressed?

One challenge is that there's information about new drugs that are out faster than sometimes the data to support their use is out there. So patients ask about it, even the doctors ask about it. But when you look at the study that's out there, it's not clear if it's helpful or not. Maybe it is.

I blame a little bit of the FDA's accelerated approval process. It's allowed the manufacturers to get their drug approved, so it is out there faster—but it's often out there before all the data has matured. The other problem with that is they still want to charge quite a bit for these new drugs.

The other aspect about these programs is there's data that sometimes we're held to, but we don't always have the information on a real-time basis—for example, hospitalization. A commercial payer actually knows pretty fast when someone went to the [emergency department] and went to the hospital because that card is swiped at the [emergency department] or at the hospital. But we may not know unless the patient tells us or later on, especially if it was unrelated to us, that the payer comes back and says, "Yeah, this person was admitted." And that's been a struggle to get that more in real-time. The problem with that is if we come up with an idea to try to lower the rates, it's hard to tell how well we're doing because the information coming back to us is so delayed, we've almost forgotten what we did. "Oh, yes, we implemented that 12 or 18 months ago, and maybe we're starting to see a benefit, or we didn't really see a benefit. Let's start again and see if we can find something better."