Getting the Patient's Viewpoint in the Oncology Quality Equation

If physicians can demonstrate they delivered good care, but the patient is left feeling unhappy, what does that tell us about quality?

According to Ana Maria Lopez, MD, MPH, vice chair of medical oncology and chief of the New Jersey Division of the Sidney Kimmel Cancer Center at Thomas Jefferson University

in Philadelphia, Pennsylvania, it may mean that physicians are using the classic value equation of quality over cost—although an update would factor in customer service.

Lopez led the discussion at the Philadelphia meeting of the Institute for Value-Based Medicine®, an initiative of The American Journal of Managed Care^®, which also featured Kashyap Patel, MD, president and CEO, Carolina Blood and Cancer Care Associates (CBCCA); Michael Ruiz de Somocurcio, vice president for payer and provider collaboration at New Jersey-based Regional Cancer Care Associates (RCCA); and Valerie P. Csik, MPH, CPPS, project director for practice transformation, Sidney Kimmel Cancer Center at Thomas Jefferson University.

According to Lopez, it’s important to ask how cost is defined. What factors are considered? Before service was part of the equation, she said, sometimes “patients were still not happy with the care they were receiving, although we could say demonstrably that it was quality care.”

From the perspective of a physician, the things that mattered— improved clinical indicators, fewer adverse effects—might not be the things that mattered to patients when they were asked. Often, patients being treated for cancer mentioned things that had nothing to do with their medical care: less time waiting, no problems parking the car, good food in the cafeteria.

As an oncologist, Lopez said, “That has nothing to do with me and quality care, but it has to do with quality of life. And we have the data that improvements in quality of life improve outcomes.”

So, as the population ages, and more people receive a cancer diagnosis—as the disease is diagnosed earlier and treatment costs rise because patients live with the disease for longer periods— quality of life and patient experiences are rising on the radar. If a patient has a rough time parking every time they come to the clinic, and has checkups every 3 to 6 months for several years, that’s a problem.

What can be done? Lopez said the future lies in integrated practice units, which identify conditions and map out the delivery process as far out as possible. “When you do that, you realize care crosses department lines and service lines, and really needs lots of coordination,” she said. Integrated care allows the health system to ensure that the right care is delivered to the right patient at the right location. A single electronic health record (EHR) is key to a better experience.

It’s also important to help the patient become more effective and responsible for their own care, Lopez said. “This really is a partnership,” she said. “We really want to engage the patient, so they can be a part of this experience.”

Using metrics to measure quality, service, and cost—and to reward innovation—will require that health systems do what’s in the patient’s best interest, even if it sometimes means competitors within a given market work together, Lopez said. But as practices in the Oncology Care Model (OCM) have seen, when clinicians get the opportunity to see how they compare with their peers, they will say, “I don’t want to be the most expensive person.”

Pathways help decrease variability and cost, she said; the adherence target should be in the range of 70% to 85%, so there is allowance for individual circumstances and adaptation to new knowledge. Health systems must ask what processes their pathways use to incorporate innovation.

But Lopez offered a word of caution about metrics.

“Often,” she said, “we measure what is easy and most accessible, and that may not be what’s giving us the most value.”

Better Patient Access: the "Lowest-Hanging Fruit"

Some practices in the OCM have struggled to achieve savings, but CBCCA isn’t one of them. Patel presented data showing that the relatively small oncology/hematology practice of 5 oncologists and 1 mid-level practitioner has seen success under the model. After up front investments of $715,000 including capital costs on technology, the practice is on track to achieve annualized savings of $550,000, while the savings for Medicare are $1.08 million.

Patel insists there’s no hidden formula. “The one thing that helped us the most was expanded access,” he said. By keeping 2 appointment slots open each day for walk-ins or same-day patients, and by encouraging them to simply come in or use an urgent care center instead of the emergency department (ED), the practice has not only saved money but improved quality of life—for both patients and the doctors.

“We’ve reduced calls from 10 every night to 1 to 2 every night,” Patel said. “It’s not rocket science. See the patients when they need to be seen.”

The practice saves money another way: Patel and his fellow oncologists evaluate the OCM feedback reports themselves, making adjustments instead of using consultants, as larger practices do.

Patel even makes some home visits, especially for patients who live in remote areas. It’s all part of embracing what’s required in the OCM, which calls for reducing the burden on the patient.

At the start, CBCCA leaders asked the staff for ideas on how to fully engage patients.

“They asked, ‘Can we have a holistic approach?’” Patel said that besides things like upgraded computerized axial tomography scan technology, employees developed an education booklet with staff photos so patients know everyone’s name and created a calming garden and fountain within the facility. One physician serves as a voluntary chaplain, and there is great attention to spirituality and end-of-life care.

Physicians also have embraced the use of biosimilars, especially filgrastim-sndz (Zarxio), to promote growth of neutrophils and prevent infection. Patel said the practices has not experienced resistance from patients to using biosimilars.

Their success has not gone unnoticed. The Center for Medicare and Medicaid Innovation is working with CBCCA to help it become one of the first oncology practices to take on 2-sided risk, and Patel is exploring innovative reinsurance ventures with other practices around the country that would make this financially feasible.

In Patel’s view, it all comes back to the basics. “It’s about instructing the patient to come to the office when they need to,” he said. “Improving access is probably the lowest hanging fruit that our system has not emphasized.”

The Value of Partnerships

RCCA operates in 4 states and treats 33% of all cancer cases in New Jersey. Ruiz de Somocurcio said this means dealing with a variety of payers and value-based care initiatives, from the

OCM to bundled-payment programs with commercial payers, the largest being Horizon Blue Cross Blue Shield of New Jersey.

“When you’re in these programs, it’s absolutely critical that you work with community physicians outside of your walls,” he said. These are all total-cost-of-care programs, so the oncologist is respon- sible whether the patient also has diabetes “or even if they get hit by a car.” Figuring out how to find value by working with the independent physician is key, “based on site of service alone,” Ruiz de Somocurcio said. And health plans have been receptive.

As he explained, value-based care in oncology isn’t happening in a vacuum. Mergers between Cigna and Express Scripts, Aetna and CVS, and collaborations among Amazon, JP Morgan Chase, and Berkshire Hathaway are just some examples of healthcare realignment. “That’s going to impact choices,” Ruiz de Somocurcio said.

While the market shifts toward downside risk, he said RCCA is determined to get there ahead of the curve, and things seem to be moving toward an oncology medical home model, with quality metrics that focus on advanced care planning, pain, and management of depression, alongside cost metrics that target ED and inpatient admissions, as well as end-of-life care.

Data sharing is key. To get data, an entity must give it as well. But without data, taking on additional risk makes little sense. Doing so has revealed that the highest-cost patient isn’t just the patient with cancer; rather, it’s the patient with existing comorbidities, like congestive heart failure, who develops cancer. Scrutinizing data has also shown:

• Post acute care costs are 2 times higher than national averages compared with other OCM practices.
• New Jersey admits too many patients with cancer who appear at the ED, and this is consistent across all hospitals.
• End-of-life care needs improvement, particularly with physician buy-in.

Meanwhile, providers who are not in the OCM are adapting the impact of the Merit-based Improvement Payment System. CMS, Ruiz de Somocurcio said, “is creating winners and losers,” which will further drive consolidation.

What Do Stakeholders Value?

Csik gave an overview of the many initiatives attempted over the past decade to move reimbursement away from fee-for-service to outcomes-based models. Although the Trump administration initially balked at continuing some value-based models that started under its predecessors, that seems to be shifting, with HHS Secretary Alex Azar announcing November 8, 2018, that a radiation oncology model would be coming shortly.¹

It’s important to understand how different stakeholders define value. Patients want to know that the doctor they are seeing is in network. Physicians want a streamlined referral process. Payers want cost control.

Csik described an approach to practice transformation that included many of the same elements that Patel and Ruiz de Somocurcio included: having clearly defined goals, investing in technology, minimizing clinical variation, using data to promote accountability, reducing trips to the ED and unnecessary hospitalization, and improving end-of-life care.

The key to it all, she said, “is the commitment— staying the course. I think all of us that have participated in the Oncology Care Model have recognized the many shifts and changes that CMS has made in the last 2-and-a-half plus years in that program and they will continue to make in the remaining few years of the program. That agility is something that’s really critical in terms of our ability to sustain progress.”

Early efforts at value-based care, “heightened our awareness but didn’t really give us a framework,” Csik said. The OCM did just that and required Jefferson to learn and adapt to the data it was receiving.

Accelerating the process will happen through several strategies:

• Data optimization, which calls for “digging in” on performance and cost, and sharing both
• Incorporating a pharmacy strategy that includes an evaluation process for making therapy switches
• Improving navigation strategy and building a team of nurse and lay personnel, across disease states
• Instituting end-of-life strategies that include supportive medicine and social workers

Csik credited the rise of the OCM with driving conversations about improving care that would not otherwise happen. The key now is not just focusing on what payers need, but what patients want as well. “We need to understand what the stakeholders value,” she said.REFERENCE

1. Caffrey M, Inserro A. Azar announces mandator oncology payment model is coming. The American Journal of Managed Care^® website. ajmc. com/newsroom/azar-announces-mandatory-oncology-payment-model- is-coming. Published November 8, 2018. Accessed November 21, 2018.

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