Changing Trends in Oncology Practice: Value-Based Care and an Empowered Patient

What are the biggest drivers of change in oncology care and what needs most attention? This was the crux of the discussion during an early panel at the Association of Community Cancer Centers' (ACCC) 44th Annual Meeting & Cancer Center Business Summit, held March 14-16, 2018, in Washington, DC.

Deirdre Saulet, PhD, practice manager, Advisory Board, led the discussion by introducing findings from the 2017 Trending Now in Cancer Care Survey, which was developed through a partnership among ACCC, the Oncology Roundtable, and the Advisory Board. Saulet was joined on the panel by Jo Duszkiewicz, MSA, vice president and administrator, Renown Health Institute for Cancer; and Mark Liu, director of strategic initiatives, Mount Sinai Health System.

There were several key takeaways from the survey, which had a majority of respondents from nonteaching community hospitals, followed by teaching hospitals and academic medical centers:

• The cost of drugs or new treatment modalities (68%), as well as physician alignment around services and program goals (47%), were top threats to the growth of future cancer program growth.
• Respondents felt that clinical standardization (63%) and drugs (62%) presented a significant opportunity for cost savings.
• Market consolidation was a common theme among survey respondents, with 75% reporting that their group had partnered with an existing hospital or health system and 36% had merged with a private oncology practice.
• Regarding information technology, data abstraction and interoperability of electronic health records were listed as significant challenges.
• Just over half (51%) agreed that prior authorization had significantly increased in the 12 months prior to the survey.
• There exist staff shortages, especially for oncology nurses, medical oncologists, and advanced practitioners.

Saulet then invited Duszkiewicz to share how Renown Health Institute for Cancer has adapted to the changes.

Renown’s health system is a combination of acute care, transitional care, network services, and insurance services, Duszkiewicz said.

“Understanding where patients are, where they got their treatment, drawing out specifics of treatment into EPIC, and then ensuring we have all the information is difficult,” she explained. It is further complicated by the fact that Renown works with many rural community practices, which may be 200 to 300 miles away.

“We do practice oncology telemedicine for a few of our communities, in parallel with medical oncologists conducting site visits,” Duszkiewicz said. “We also link with primary care in those areas. However, we found out that primary care physicians were struggling with diagnosis and the tests that were needed.” Consequently, these struggles resulted in an extended time to diagnosis.

To unscramble this situation, Renown developed a solution: the intake oncology coordinator (IOC) process, which included conducting a phone triage first, then a chart review, and finally, bringing the patient in for a clinic visit.

“On evaluating the data, we see that 31% of patients get phone advice, and 25% do a chart review, but 44% of patients who are referred come to see the advance practice nurse,” Duszkiewicz said, adding that IOC has resulted in a very successful clinic.

Duszkiewicz then presented trends within the fee-for-service reimbursement model from 2013 to 2022, which show that productivity adjustments have been increasing, from $4 billion to $94 billion, she said. The shift now is toward value-based contracts, such as the Oncology Care Model (OCM), alternate payment models, and others.

However, Duszkiewicz asked, are shared savings feasible in oncology? She shared data from the Miami Cancer Institute on the results of adopting a value-based approach to care:

• First-year savings were modest: $354 per patient per year (pppy)
• Second year: $2235 pppy
• Third year: $9095 pppy
• Fourth year: $4917 pppy

She explained that clinical pathway adherence had a significant impact on the savings seen over the first to the third year. However, the diminishing returns of savings in year 4 have triggered more cost savings initiatives within the institute that are focused specifically on the inpatient population.

Next, Liu spoke of Mount Sinai’s practice changes. To be able to provide high-value care and broaden patient access, the hospital has developed several projects and programs, including creating disease management teams (DMTs), building clinical pathways programs, establishing a chemo council, and using Epic_Beacon to monitor the clinical pathways being used.

DMTs, Liu said, are focused on quality metrics, value-based care, care pathways, tumor boards, and clinical trials. They are also tasked with narrowing down the quality metrics to avoid overlap and integrating OCM quality metrics with disease-specific metrics for tracking and decision making.

Saulet then spoke about the changing dynamic between the patient and the provider. “Cancer patients are acting independently and asking questions,” she said. “Patients are taking more responsibility for their healthcare costs. Patients have information available at hand on sites of care as well as drugs and treatment. Plus, the patient—provider relation is changing—there are rising expectations on service, with patients feeling more empowered and being skeptical about the care they receive.”

Saulet said that patients with cancer are doing their research: 25% of patients who were surveyed said that they are spending an hour on average reviewing oncologists and 41% said they had researched their treatment options.

Precision medicine is also evolving rapidly, Saulet said, with 92% conducting predictive tests, 92% conducting single-gene tests, 72% conducting small panel tests, and 31% conducting whole-genome sequencing.