Behind the Scenes, Value Is a Struggle

Cheaper Treatment Options Are Not Covered

Delivering patient-centered care is not an easy task in an increasingly complex environment, participants at the 4th Annual Institute for the Future of Oncology concluded at the June meeting. It’s tough enough that the pace of medical advances keeps oncologists hopping to keep up, and it doesn’t help that many aspects of care are not covered by payers, but forum participants enumerated other frustrating conditions for which solutions seem far off. These concerns were outlined in a white paper released last month by the Association of Community Cancer Centers (ACCC).Institute members said financial incentives are sometimes misaligned, to the point that it may be easier to spend $10,000 on a drug that could have been avoided were it been possible to obtain payment for sending a nurse to a patient’s home at a much more modest cost of $1000. A variation on this theme was provided in the retelling of a case where a practice sought to visit nursing homes twice a week in order to administer a medication to patients with myelodysplasia so that the patients wouldn’t have to be transported to the cancer center or a hospital. However, payers wouldn’t pay for the drug unless it was administered in an office or a hospital. “Because of that, patient-centered care was killed—cut off at the knees,” the unidentified participant said, noting that the practice in question couldn’t afford to provide the drug without payment.

Another forum participant noted that the more bureaucratized and administratively centered the practice of oncology becomes, the further away from delivering actual personalized healthcare practitioners end up. The example of this he gave was that of precertification needs, which the unidentified participant described as mind-numbingly bureaucratic. “In the end, is that providing any true benefit for the individual patient?” he asked.

One problem forum participants said needs to be overcome in delivering better oncology care is the tendency to put labels on departments. They said current thinking tends to be skewed toward funneling patients into respective treatment centers rather than addressing their individual needs and then deciding what to do. This problem, an unidentified oncologist said, is readily apparent in the hallways of cancer centers where you see department signs that say “Thoracic Surgery,” “Radiation,” and “Chemotherapy.” If a patient comes to an oncologist with lung cancer, that’s where the directional system should begin, the oncologist said. “Our institutions and our payment systems and our infrastructure have evolved around the needs and the availability of the provider.”

Some in oncology tend to think that those with MDs after their names do not get the type of training they need to be capable of seeing the patient through the proper lens of empathy. Conversely, nurses are trained to function through the “psychosocial paradigm” and in that respect can deliver the appropriate level of patient-centered care, an unidentified participant said. “How medical students are educated, and how nursing students are educated, and how they approach the patient are drastically different.” The ACCC does offer a means to address this problem via a training program and resources that are aimed at bringing health teams into better alignment with patient-centered treatment goals.

For their part, physicians counter that it’s tough to deliver good patient-centered care in the space of a 15-minute visit. They have to be as efficient as they can be, and they cannot stretch their abilities to the desired extent. For example, the decisions that get made inside that 15-minute space of time with the patient tend to be “short term,” said one unidentified participant. “There aren’t any decision-making tools that help. You’re the patient’s cancer doctor for a short period of time. You’re dealing with the patient’s insurance company for a short period of time.”

And whereas time is often insufficient to accomplish a long list of tasks, physicians can find themselves pondering a multitude of drug alternatives, much like bewildered grocery shoppers staring at a multitude of brands in just the cereal aisle. “Lung cancer is not a disease with one treatment,” said a medical director. “There are genetic mutations and different options for every mutation. Yet, there are no head-to-head comparisons of those drugs, and there is a lack of clear guidelines as to which drug is the right drug for the right patient.”

Tearing Down the Data Wall

“The example I give is the 90-year-old with kidney dysfunction and pancreatic cancer,” the director said. “I can give him FOLFIRINOX, I can give him gem-Abraxane, or I can give him gemcitabine. But without any comparative trials, I have to go with gut feel, and there’s no way to get value into that equation,” he said.Another thing standing in the way of good quality patient-centered care is the film of opacity between people and departments that prevents the smooth flow of data for things like payment, best practices, and the cost of research and drugs. This all gets in the way of peer learning and the sharing of best practices, said a practice administrator.

Electronic health records can be lumped into this category of frustrations. Not only do different EHR systems not communicate with each other, even within a care system there are information access problems. In one practice it was explained that inpatient and outpatient records are not connected, which makes it difficult for patient navigators to do their jobs and answer questions about medical records and financial obligations. One program director said that a nurse coordinator was unable to prepare patients for their appointments because she couldn’t access new patient information to know what was needed before patients had to meet with the doctor.

Whereas a little integration of EHR systems would be a good thing, too much integration of cancer centers via mergers and acquisitions has had the effect of institutionalizing patient care and diluting the level of personal attention that is essential to patient-centered care, the participants said.

Finally, good patient-centered care means not putting too much responsibility on the patient and not ignoring the patient’s own preferences and persuasions, the participants said. For example, it is often left up to the patient to coordinate care that is far too complex for that individual to manage effectively. At the same time, it is important to know something about a patient’s cultural and gender-related standards and to allow the patient to some extent to define the value of the care being delivered. Some patients may not even want to know much about their condition and would rather leave some decisions up to the practitioner.

The forum report covered numerous current issues in oncology, but it also stated that the ACCC has various tools designed to help clinicians improve their communication with patients, including but not limited to a set of tools and resources to improve oral drug adherence, psychosocial distress screening, and communication with patients about metastatic breast cancer.

“New programs designed to address the financial barriers to providing patient-centered care, particularly the Oncology Care Model, have the potential to address many of these obstacles,” the report concluded. It defined patient-centered care as including seven core elements: patient stories; navigation and coordination; interdisciplinary teams; appropriate financial incentives; greater education; information technology connectivity and transparency; and decision-support tools.

Association of Community Cancer Centers. Empowering patients, engaging providers: the future of patient-centered care in oncology. http://accc-cancer.org/institute/pdf/2016-WhitePaper-Empowering-Patients-Engaging- Providers.pdf. Published October 2016. Accessed November 11, 2016.