How Education, Access Can Optimize Value-Based Cancer Care Delivery

As he opened his talk during this year’s Patient-Centered Oncology Care® 2020 conference, Harlan Levine, MD, president of strategy and business ventures at the City of Hope comprehensive cancer center, highlighted the chasm present in oncology today.

“On one hand, it’s an amazing time in oncology with great discoveries that could help people. On the other hand, the system itself is struggling with both affordability and access,” he said.

Levine said getting the most from innovation within oncology care requires the US health care industry to reimagine how cancer care is delivered. He said it calls for understanding how cancer is different from all other clinical conditions, particularly when considering strategies best suited for other diseases.

In examining models tailored to manage diabetes or cardiovascular disease, for instance, Levine said the pathways have clear, established goals, specific interventions backed by evidence, and measures that tend to align with patient interest. He compared these dynamics with cancer care, which affects approximately 0.5% of the general population in new diagnoses each year, and said best practices in oncology are rapidly evolving.

Building on the differences between cancer and other clinical diseases, Levine said that in oncology, typically the first chance of cure is the best. The timeframe afforded to physicians managing patients with diabetes or high cholesterol differs from that for patients with cancer, with patient behaviors (exercise, smoking cessation) also not having extensive effect on care in oncology. Although patient participation is important, medical interventions of chemotherapy, radiation, and surgery make the biggest difference in oncology, Levine said.

Cost also presents a significant obstacle for those seeking cancer care, with many of the latest innovations in treatment totaling hundreds of thousands, if not millions, of dollars. Delving into the current landscape of value-based health care in oncology, Levine said that among payers, process measures are still prioritized instead of variables such as survival and quality of life.

To address the challenges of value-based care in oncology, Levine said defining value is the first step. It must capture how patients weigh the value of their care.

“Let’s take a look at how the current tools work in oncology specifically, and then if we decide they aren’t applicable, let’s be willing to let go of old habits and not do just what is easy for us to do,” Levine said. “Let’s truly start with a new design, a new vision where we make the cancer patient and their family the primary customer, and then when you do that, then you’re at a point where you can really begin to build a new model for the future.”

The setting in which patients with cancer receive care can play a significant role, Levine said, with a 20% difference in 5-year survival observed among patients in a National Cancer Institute–designated cancer center compared with those attending community practice and acute medical centers.

Although he did not suggest that every patient should be treated in these centers, Levine said a significant catalyst for this survival difference is use of genomics, which he said has revolutionized how physicians think about, treat, and diagnose cancer. A major issue is the pace at which cancer care is evolving; it can become daunting for oncologists, with 4 out of 5 having said in multiple surveys that they are not completely confident in their ability to keep up with the changes.

“This is not a negative comment about community oncologists. In fact, they play a key role, but it’s just a comment to say the world is different,” Levine said. “Genomics is changing everything, and we need to do something to fill that gap.”

This deficit in equitable cancer care poses a challenge, especially among those who do not live near major cancer centers. Levine said the primary goal should not be to create a system where every patient with cancer goes to a major center, but rather to find ways to help community oncologists receive the latest expertise to ensure that variables crucial to value-based cancer care, such as survival and quality of life, are prioritized. Additionally, eliminating low-value care can prove significant in terms of cost and quality for oncology practices.

When assessing tools available today in oncology, including narrow networks, accountable care organizations, and centers of excellence, each option has the potentialto improve care delivery, but all are evolving and subject to issues related to cost and availability.

These are factors that Levine and his colleagues at City of Hope account for when strategizing how to optimally create a system that delivers the care that patients and their respective family members want without subjecting them to high cost.

“We need to acknowledge that both academic medicine and community medicine have value, and we need to find a balance between the two,” he said. “For complex cancers or for those with rapid-changing best practices, we need to get access to expertise. We need to focus incentive payments on delivering the best care, not necessarily the lowest-cost drug,” Levine said.

Continuing the discussion on steps needed to improve cancer care, Levine spoke on myriad issues, including the implementation of decision support programs, assisting patients in finding clinical trials, and improving access and outcomes for certain minority, racial, and ethnic groups. Levine highlighted the creation of a separate entity within City of Hope, called Access Hope,¹ that works to educate cancer centers nationwide about the latest innovations in oncology and reconfigure how value-based interventions could occur.

Levine cited the need for efficiency in oncology, not only to improve treatment and outcomes, but to reduce costs as well. Ensuring community cancer centers have the expertise and tools necessary to provide uniform care nationwide can also assist in bridging the gap present in oncology, he said.

“Really, what’s important is we’re able to do it inthe convenience of one’s market. So the patient, the family don’t feel like they’ve had their lives disrupted to get value-based care, while at the same time, having access to all the great changes that are happening in the oncology revolution today,” Levine said.

Reference

Fighting cancer with everything we know. Access Hope. Accessed October 15, 2020. https://www.myaccesshope.org/