Keeping Oncology Care Patient-Centered

Joseph Alvarnas, MD: Welcome back, and thank you for joining us. I want to welcome to our program Dr. Bhuvana Sagar, a national medical director at Cigna Health Care in Houston, Texas. The issue of patient-centered care is being emphasized across the cancer care continuum, but it remains a work in progress. Dr. Sagar, at what stage does cancer care become patient-centric?

Bhuvana Sagar, MD: I think that patient-centered care becomes important at the time of diagnosis, possibly even at the time of suspicion of cancer. It’s a very emotional time. I was just talking to a couple of folks yesterday who have a great understanding of insurance and cancer. The minute that there’s a suspicion of cancer, everybody immediately gets into a panicked state. So, I think patient-centricity should begin right there. Physicians should take the time to explain to patients what they think is going on and try to make an educated guess. The time until they get the biopsy results is probably the most critical. Once they get the biopsy and the scan is done, the physicians should try to sit down and have a clear conversation about what the diagnosis is, what the stage of cancer is, and what the treatment options are.

Of course, that part is probably much more important, but as we go along through the journey of cancer, early palliative care becomes important. The management of symptoms is key. I think there has been a lot of controversy between palliative care and hospice care. I don’t think those should be confused. Palliative care early on in the journey is critical in transitioning the patients, and they don’t have to have terminal cancer, in my opinion.

Joseph Alvarnas: Bob, as someone who is intimately involved in the development—dissemination—of practice guidelines, is there a point in the decision node when patient-centricity is turned on like a switch?

Robert Carlson, MD: No, I think patient-centricity should be a constant over all of healthcare, not just cancer care, but also all healthcare within the United States. Everything that we do should be trying to optimize outcomes for patients. I think one of the things we have to be cautious of is that patient-centric care doesn’t always mean the patient is happy. There are things we do sometimes that make patients unhappy but are for their own good. “You need to lose weight.” “You need to stop smoking.” “No, I can’t give you narcotics for that.” “No, your bronchitis won’t just be helped by antibiotics.” Those are things that are good for patients in terms of outcomes but don’t always make patients happy. Hopefully, most of the things we do for patients that are patient-centric make them happy, but the well-being of the patient needs to always be at the center of what we do.

Joseph Alvarnas, MD: I’m interested. You say optimize outcomes. What outcomes? I think that gets to the question of who defines which outcome is important—is that the physician? Because I know if we look at any medical journal, whether it be The Wall Street Journal or The New England Journal of Medicine, the only things we report on are progression-free survival or overall survival. At what point do patients define what an important outcome is? And are we as good of a delivery system as physicians about considering patient perspectives on what’s important?

Robert Carlson, MD: No, we’re not good enough at that, and we need to be better. That, today, is typically considered patient-reported outcome and what is optimal for them and so forth. But the challenge is, what are the best outcomes? What is quality? What is value? All those things are somewhat in the eye of the beholder, and I think we’re in a situation where there are multiple, different perspectives—all of which are probably valid. The truth for the utilitarian system of healthcare in the United States is probably somewhere in between all of those different perspectives.

Leonard Lichtenfeld, MD: Patient-centered care is such a great term, until you’re a patient and see what it really is like. I think the first thing that we need to do in this country is start understanding the consumer and the patient. We need to start thinking about who’s at the center of this equation, because so much of what we do and how we do it may be called “patient-centric,” but very few people actually offer patient-centric care.

We’ve been working on this for a long time, the patient-centered medical home. Some places do it well, a lot of places, unfortunately, don’t. We have to figure out cost, reimbursements of people. It’s a topic that’s top of mind for me and for many others because we have to start paying attention to the quality of life, the quality of experience. We have to start understanding more about it, and we don’t do that. This is an industry, and when I say “industry,” it sounds terribly sterile, doesn’t it?

But these are people’s lives, and we need to figure out how the person who we’re treating perceives the care we’re offering. We have to start thinking about what we can do to make that experience better. So, I’ve sat in meetings where we’ve spent a whole day or 2 days talking about patient-centric care, and everybody brought their own perspective to the table. Everybody had a different definition of what makes patient-centric care. It was actually a very interesting discussion, depending on your perspective and where you’re coming from. So, I take a look; patient-centric extends, for me, to electronic health records.

Go become a patient and see what the experience is like. Go find out when you walk in with a piece of paper, writing down and trying to remember all your medical history, giving it to somebody who then has to transcribe it into a system—who doesn’t put the right dates, doesn’t put the right disease, and you have no way of correcting that. That’s where we start from: computer systems that don’t talk to other computer systems or people who are critically ill like cancer patients, who need to go from place to place to place and they wring their hands because they have to carry their records from place to place because the systems don’t communicate. So, patient-centric means a lot of things to a lot of people.

I think that we can do better—we need to do better. We need to pay attention, and I hope we’re going to get there. There are a lot of things that we all have to pay attention to. We have payment, but we have to figure out how to make sure the payment ends in the right place. Centers for Medicare and Medicaid Service, or CMS, have put a model in place called the Oncology Care Model. The centers, the practices, that participate—along with not only CMS but also a number of other private payers who’ve come together to do this—pay a certain amount per month for patients who are on chemotherapy or on active treatment. Hopefully, that money will be taken to try and improve the quality of care.

Urgent Care centers, or off-hours facilities—it can be a doctor’s practice; it doesn’t have to be an urgent care center—try to take care of patients at night, on weekends, or maybe even give treatment on nights and weekends so that somebody who’s trying to work and hold their life together has an option. What about on a weekend—did somebody have to go to the Emergency Department to get IV fluids, because, unfortunately, they had a reaction to the medicine? Severe nausea and vomiting? Maybe we need to rethink this.

There are doctors and groups out there that have gotten together and are thinking about this. I’m aware that ASCO has started a program to try and create a medical home to pay attention to these issues and to try to rethink how we give our care. We need to do more. I can tell you that the American Cancer Society is very concerned in making sure that patients have access to high quality care and that their needs are met, whether they be immediate or palliative care.

One of the interesting questions is, when does it start? When does all that begin? It begins the day you walk in the doctor’s office and somebody says, “You have cancer.” That’s when it starts. It maybe starts in a little different way than when you walk in the door and somebody says, “I’m sorry to tell you your cancer has come back.” There may be different conversations, but it’s the theme that’s important. And in putting the patient’s center of experience, we could do a lot better.