Value-Based Care Asks: Are We Being Kind to Our Patients?

There is no clear-cut answer to the question of what patient-centered care under the umbrella of value-based care should look like. However, what is clear is that dialogues on the topic continue to swirl around the debate of saving dollars vs saving lives and which should be top priority.

Discussions held during the 11th Annual Patient-Centered Oncology Care® meeting, held November 9-10, 2022, in Nashville, Tennessee, demonstrate that efforts to shift away from fee-for-service reimbursement put a spotlight on the complex relationships in health care delivery, with the ultimate question, “Is the system and its players kind to patients?”

That question, posed by Bo Gamble, director of quality and value with the Community Oncology Alliance (COA), comes near to encapsulating the many areas he and his copanelists addressed for their impact on patients. The panel discussion, “Quality and Value Initiatives That Make a Difference,” was moderated by Kashyap Patel, MD, CEO of Carolina Blood and Cancer Care Associates and immediate past president of COA. Alongside Gamble, the panelists included:

• Rajini Katipamula-Malisetti, MD, practicing medical oncologist with Minnesota Oncology;
• Kathy Oubre, MS, CEO of Pontchartrain Cancer Center; and
• Leah Owens, DNP, RN, BMTCN, OCN, executive director of care transformation at Tennessee Oncology.

“Yes, we had the OCM [Oncology Care Model],” Patel said at the start of the discussion. “One big challenge I face all the time is: To whom should it matter? Does value mean saving dollars or saving lives?”

Statistically, Patel noted some worrisome facts, including the following:
Thirty-four percent of cancer deaths are preventable.

Over the duration of PCOC, 2000 individuals in the United States would have died from something that could have been prevented in the 21st century.
Babies born to mothers in the French Quarter of New Orleans, Louisiana, have an average life span of 55 years compared with close to 80 years for babies born to mothers 10 mi northwest.

The reasons for these are multifactorial and they include social determinants of health (SDOH), access to care, and access to testing, Patel explained, and they all come back to quality and value. “There are lots of moving parts, and we need to look with an eagle’s eye at the panoramic view of what the health care ecosystem is: transactional, confined, fragmented, and compartmentalized,” he said.

As oncology practices transition from the OCM to the Enhancing Oncology Model (EOM), Owens noted the difficulty inherent with the OCM is gaining an understanding of what value-based care is. “For us, it took time. Once we got our teams in place, everybody was united with a common goal: We all wanted to do the right thing for the patients. We didn’t want to just check a box. We had ongoing discussions with payers on what makes the most sense.”

Over the past 5 to 10 years, accountability has moved to the forefront of this debate, which is something health care has not had before, Gamble said. Noting the myriad of swirling opinions—from patients, physicians, and payers—Gamble also noted the importance of aligning goals from a quality and value standpoint. “We’ve got to look beyond the short-term return on investment. We [have] to look for the long-term [return on investment],” he said. “We’ve got to stop looking at the price of the drug and look at the price of the entire journey.”

The panelists also discussed palliative care and advanced care planning. Here, Patel noted that close to 80% of individuals in the United States have not talked about advanced care planning with their families or loved ones. “Right now, palliative care is lumped in with hospice, and we really get to palliative care discussions more when patients are admitted to the hospital at the end of life. I would like to see…these discussions integrated earlier,” Katipamula-Malisetti said, regarding how best to broach this value point to improve quality of care and stress the overall importance of palliative care to value-based care.

Having such conversations ahead of time—instead of when a patient reaches stage IV cancer, for example—could allow oncologists to improve symptom control and decrease hospitalization secondary to symptoms and earlier hospice.

“You want to demystify it,” Oubre said. “We try to look at it as responsible adulting. At Pontchartrain, we have these conversations at the treatment education visit and then we put a workflow in place, so we are bringing it up every few visits.

“There are so many things we want to do to drive better care and quality for our patients: survivorship care, advanced care planning, [addressing] co-pays for generic medications—[all these things]” she said. “But we can do better.”

“Make it easy for the patient to do the right thing, that’s value,” Gamble said, quoting A. Mark Fendrick, MD, of the University of Michigan, who is co–editor in chief of The American Journal of Managed Care®, sister publication to Evidence-Based Oncology™. “Get rid of co-pays so they can make the easy things happen and make it harder to do the wrong things. Let’s fix it.”

Addressing Health Equity
“How do you see the role that the new model can play in terms of identifying problems vs addressing problems?” Patel asked, shifting the discussion to the upcoming implementation of the EOM and its potential impact on breaking down barriers to health equity.

“We’ve got to have solutions, and the model is not sensitive to where those solutions are available in a community and where they’re not. Who knows what the right intervention is? There are 300 [electronic patient-reported outcomes],” Gamble said. “Help us help our patients as best we can, but don’t hold us accountable for the patient’s entire life and everything they need. That’s kind of crazy.”

Oubre echoed these sentiments, noting that making progress against health disparities is a challenging issue; asking patients to provide so much data does not necessarily mean they are comfortable providing that information or that they trust in their care providers. “Do you really want to admit to your physician that you have trouble affording your groceries? These are hard conversations that get built with your care team over time. That’s not something we can address at a new patient visit,” she said. “But as organizations, we’ve been addressing SDOH for a long time without needing to be told to do it.”

The learning process is ongoing and improvements will continue. However, it takes time and resources to learn how to do things better, to redefine the health care system, and the panel was clear in stressing that all parties involved don’t want to be told what to do. Yes, they want to learn to become more efficient and effective with care delivery, to put the value back in value-based care, but they want to do so through collaboration to become a voice for their patients.