Cancer Care and Accountable Care Organizations: The Unknown Patient Experience Landscape

October 15, 2013

ACOs can provide the structure, but it’s up to the stakeholders to establish mutually agreeable goals for this new care delivery model. Achieving these goals will require a different set of dialogues and conversations among stakeholders, and patients and their advocates must have seats at the table.

Healthcare is routinely front page news. However, what is presented to the public is often out of context and only partially true. The general public has many misperceptions about healthcare delivery, and certainly needs impartial guidance and empowerment to understand fully the implications of healthcare reform. Political sound bites have not helped clarify a very complicated process that is occurring in the context of clashing generational values, and that is clouded by views that lack perspective on the historical evolution of healthcare delivery, leading to unrealistic expectations. The lack of accurate, objective information is particularly keen in the field of oncology. Balanced, honest assessments of the state of cancer care that build upon a meaningful dialogue between trusted partners is the only way to move forward. Moreover, the patient experience and outcomes must be at the heart of reform.

Here, we will try to shed light on one phenomenon of the healthcare reform movement-the accountable care organization (ACO)-and on how the new ACOs will affect cancer patients.

The Affordable Care Act: Its Origins and Aims

Our current fee-for-service model of healthcare delivery has failed. Costs are rising much faster than economic productivity, and are eating up an ever larger percentage of the US gross domestic product.[1] This increase in cost is both a function of too many “units” of healthcare being consumed, and probably most importantly, of each unit being priced much higher than anywhere else in the world.[2]

Many other countries have developed mechanisms to control healthcare costs. The United Kingdom has for years used the National Institute for Health and Care Excellence (NICE) as an adjudicating body for the appropriateness and cost-effectiveness of new technologies.[3] Other countries, such as India, have chosen to more tightly control drug patents in an effort to control the costs of new drugs. Many other nations have developed low-cost, high-efficiency hospitals that specialize in particular procedures, such as joint replacement; such hospitals deliver verifiably high-quality care at a fraction of what it costs to perform the same procedures in the United States. However, none of these solutions have been deemed “workable” in this country. Instead, we have the Affordable Care Act (ACA).

The ACA reflects the perceived need for transformative change in healthcare delivery and funding.[4] The ACA has several key underpinnings. First, it defines fee-for-service as a main defect that limits progress in the control of healthcare cost inflation.[5] Second, it identifies lack of care coordination as a major shortcoming.[6] Third, the ACA aspires to enhance coverage of the uninsured and underinsured via a number of mechanisms, including expansion of Medicaid and the establishment of health insurance exchanges.[7] The proposed solutions include a new delivery model that aggregates providers into healthcare delivery units that efficiently exchange patient information and thus coordinate care. These units become accountable for both quality and cost, placing them at risk if they underperform on either account. This new delivery model, known as an accountable care organization, or ACO, also increases patient “stickiness” by associating patients with specific providers.[8]

Approximately 30% of healthcare spending (based on Institute of Medicine data) could be saved if waste and abuse could be tackled.[9] ACOs were developed to bring down costs by eliminating this waste through the provision of better coordinated care.

New Choices for Patients-But Will They Choose Wisely? Can They?

Curiously, as the healthcare debate has progressed, the only discussion of the effects on patients has consisted of occasional sound bites about “keeping the care you like.” However, there is little question that the reforms will have huge effects on patients. The first question is whether consumers have the tools they need to measure quality, and then whether they will use this information to make wise healthcare choices. Studies have shown that patients often choose physicians on the basis of the recommendation of another physician or perhaps of a friend or family member.[10] The explosion of direct-to-consumer advertising by many healthcare entities suggests that such ads do have an impact. However, this advertising invariably promotes amenities or reputation rather than evidence. And it may be a while before consumers understand the new ACOs sufficiently to select care wisely in this model. Thus, the consumer is not enabled to behave like a consumer. Furthermore, consumer choice will certainly be limited. This is particularly true where there is less population density and therefore fewer providers.

Will the ACA-and ACOs-Reduce Costs for Patients?

Medical bankruptcies, always a factor in cancer care, are at an all-time high.[11] Compelling evidence suggests that compliance is inversely correlated with cost of treatment.[12] Although third parties, such as employer-sponsored health insurance plans or the federal government, bear the majority of the cost of healthcare, increasingly this cost burden is being shifted to patients, and it is affecting their choices. ACOs may also attempt to improve the quality of care and to control costs by sharing risk with providers; however, experience with this latter approach is still immature.

How Does Cancer Care Fit Into the ACO Model?

Cancer care represents a special case. The care of cancer patients is complex and expensive. Cost increases are driven by rapid technological advance, and there is every reason to believe this trend will only accelerate.[13] There is, without a doubt, tremendous variability in cancer care, which represents an opportunity for improvement.[14] Enter the ACO.

How oncology fits in the ACO model is unclear, however. While there is no universally agreed-upon formula for reducing oncology costs, multiple pilots indicate that the use of software-deployed tools at the point of decision, and back-end reporting of activities and results to practices, do bend the cost curve. In theory, the implementation of medical home principles should foster patient-centric care by enhancing shared decision making, leading to fewer side effects and adverse events, as well as to a better patient experience. However, at present patient care varies widely, and the consequences of this variability have not been well studied. Moreover, there is no body of literature describing what the changes in the delivery system might mean to patients. Many cancer patients and their families have a difficult time navigating the system. Quality has been poorly defined, and as a result rarely measured and reported. Cancer patients will experience greater benefit from ACOs once more uniform evidence-based guidelines and processes are put in place.

Up to this point, solutions to the problem of soaring oncology costs have focused on use of Clinical Decision Support (CDS) tools (using reporting of clinical characteristics to facilitate the offering of evidence-based treatment options at the point of care) and enhanced clinical service offerings, such as the Oncology Patient–Centered Medical Home (OPCMH).[15] However, these solutions have only gained traction in community oncology practices. At the present time, about 60% of cancer care is delivered by community practices and 40% by hospital-based providers. Over the last decade, hospitals have aggressively acquired oncology practices.[16]

So what does this mean for ACOs? The ACO as currently constructed is a primary care solution.[17] But the goal is full integration of both primary and specialty care. The most successful ACOs to date are integrated delivery systems. However, the field of “aspiring” ACOs numbers many hospital systems among its ranks. The analytics required to make cancer care profitable in an ACO model are not being developed in a meaningful or standardized way. Instead, hospitals likely are relying instead on the profits generated by 340b pricing. Yet it is not difficult to predict that as ACOs take on risk for cancer care, the need for this analysis will become paramount to the wellbeing of the ACO. Ironically, the tools that the community practices have employed, such as the CDS tools and OPCMH model, will have new relevance for hospital-employed providers, and will establish the groundwork for the effective contracting of transformed practices with ACOs.

An ACO Model That Truly ‘Works’ for Cancer Patients: What Is Needed?

Where does this leave patients? For an ACO to succeed, it must strengthen the bond between the patient and the integrated delivery system.[8] The patients (and all of their healthcare costs) are “attributed” to specific providers within these systems; the providers are accountable for these costs. It is obviously in the provider’s interest to limit care outside of the system.[18] By using internal resources, the provider can control variability and to some extent unit cost. The end result, in a perfect world, will be the ability for patients to receive integrated, cost-effective care.[6]

The ultimate success of this transformation will depend on the ability to collect, aggregate, and analyze huge volumes of patient data.[19] The vision of uniform implementation of electronic health records and health information exchanges to enhance coordination of care also includes the ability to collect information on “best practices” and “best doctors.” The ability to realize meaningful data that can be used in comparative effectiveness research represents a new world for payers as well as clinical investigators. Further, with appropriate transparency, the reality of informed consumerism in healthcare can be realized.[20] Patients will have access to this information as well, and will have enhanced electronic connectivity to providers.

ACOs can provide the structure, but it’s up to the stakeholders to establish mutually agreeable goals for this new care delivery model. Achieving these goals will require a different set of dialogues and conversations among stakeholders, and patients and their advocates must have seats at the table.

[[{"type":"media","view_mode":"media_crop","fid":"17952","attributes":{"alt":"","class":"media-image media-image-left","id":"media_crop_8529149987953","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"1178","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"float: left;","title":" ","typeof":"foaf:Image"}}]]The content of ONCOLOGY’s Practice & Policy department represents a joint venture between the editors of ONCOLOGY and the Community Oncology Alliance. Articles featured in Practice & Policy are supplied by the COA as part of its mission to educate oncologists about the policy issues that affect the nation's cancer care delivery system. Practice & Policy features reflect the views of their authors and not necessarily those of the COA.

Disclosures:

The authors are all employed by Aetna; beyond this, they have no significant financial interest or other relationship with the manufacturers of any products or providers of any service mentioned in this article.

References:

1. Health at a glance 2011: OECD indicators – Why is health spending in the United States so high? November 23, 2011. Available from: www.oecd.org/health/healthpoliciesanddata/49084355.pdf.

2. Commonwealth Fund. Explaining high health care spending in the United States: an international comparison of supply, utilization, prices, and quality. May 2012. Available from: http://www.commonwealthfund.org/~/media/Files/Publications/Issue%20Brief/2012/May/1595_Squires_explaining_high_hlt_care_spending_intl_brief.pdf.

3. Rawlins M. NICE: Moving onward. N Engl J Med. 2013;369:3-5.

4. Doherty RB. The road to health reform: What can physicians expect over the next 4 years? Ann Intern Med. 2013;158:487-8.

5. Schroeder S, Frist W. Phasing out fee-for-service payment. N Engl J Med. 2013;368:2029-32.

6. Avalere. Analysis of care coordination outcomes: a comparison of the Mercy Care plan population to nationwide dual-eligible Medicare beneficiaries. July 2012. Available from: www.avalerehealth.net/research/docs/20120627_Avalere_Mercy_Care_White_Paper.pdf.

7. US Census Bureau. Income, poverty and health insurance coverage in the United States: 2011. September 2012. Available from: http://www.census.gov/prod/2012pubs/p60-243.pdf.

8. The Commonwealth Fund. Quality matters. Case study: Aetna’s embedded case managers seek to strengthen primary care. August/September 2010. Available from: www.commonwealthfund.org/Newsletters/Quality-Matters/2010/August-September-2010/Case-Study.aspx.

9. Institute of Medicine. Best care at lower cost: the path to continuously learning health care in America. September 2012. Available from: www.iom.edu/Reports/2012/Best-Care-at-Lower-Cost-The-Path-to-Continuously-Learning-Health-Care-in-America.aspx.

10. Caffarini K. Most patients rely on word of mouth when picking a new doctor. amednews.com. December 22, 2008. Available from: http://www.amednews.com/article/20081222/business/312229993/7.

11. Himmelstein D, Thorne D, Warren E, Woolhandler S. Medical bankruptcy in the United States, 2007: results of a national study. Am J Med. 2009;122:741-6.

12. Geynisman DM, Wickershma KE. Adherence to targeted oral anticancer medications. Discov Med. 2013;15:231-41.

13. Mariotto A, Yabroff R, Shea Y, et al. Projections of the cost of cancer care in the United States: 2010-2020. J Natl Cancer Inst. 2011;103:117-28.

14. Neubauer M, Hoverman J, Kolodziej M, et al. Cost effectiveness of evidence-based treatment guidelines for the treatment of non-small-cell lung cancer in the community setting. J Oncol Pract. 2010;6:12-18.

15. Sprandio J. Oncology patient-centered medical home and accountable cancer care. Commun Oncol. 2010;7:565-72.

16. Community Oncology Alliance. Community oncology practice impact report. April 4, 2012. Available from: http://www.communityoncology.org/pdfs/community-oncology-practice-impact-report.pdf.

17. Centers for Medicare and Medicaid Services Shared Savings Program. Available from: http://www.Medicare-Fee-for-Service-Payment/sharedsavingsprogram/index.html?redirect=/sharedsavingsprogram/.

18. Emanuel EJ. Why accountable care organizations are not 1990s managed care redux. JAMA. 2012;307:2263-64.

19. PwC Health Research Institute. Needles in a haystack: seeking knowledge with clinical informatics. 2012.

20. New feature helps ‘Ann’ answer important questions for Aetna members. September 24, 2012. Available from: http://newshub.aetna.com/press-release/products-and-services/new-feature-helps-ann-answer-important-questions-aetna-members.