Including the entire course of care in the efforts to improve quality and contain costs will make the short-term implementation more complex and perhaps controversial. However it will reflect the way that contemporary oncology care is delivered, and will allow for holistic care management and an optimization of cost.
The article by Dr. Eagle in this issue of ONCOLOGY summarizes initiatives to lower oncology costs. Several approaches are described that are believed to be effective in bending the oncology therapeutic agent cost-curve: implementation of clinical pathways, the episode-of-care payment model, and the oncology medical home model. As Dr. Eagle notes, however, therapeutic agents represent only one-quarter of the total oncology costs. Scientific achievements and contemporary cancer care have resulted in more than 13 million survivors in the US, with many living with cancer as a chronic rather than an acute condition. Significant cost savings and quality improvements could be achieved by applying the new approaches to the entire spectrum of oncology care, from prevention to screening, diagnosis, treatment (clinical oncology, surgery, radiation), supportive care, survivorship, and palliative care.
Of course, an effective argument could be made to focus on managing the drug costs, at least initially-you have to start somewhere, and medical oncology represents a relatively self-contained independent domain conducive to piloting new models. Nevertheless, by limiting current efforts to the oncology domain, we are also limiting their applicability and effectiveness for the entire episode of cancer care. Current efforts do not address one of the main features, and challenges, of contemporary cancer care: the necessity of involving multiple domains concurrently in care for a single patient. For example, a colorectal cancer patient may receive care from over a dozen domains: gastroenterology; surgery; medical oncology; radiology; radiation oncology; pathology; primary care; comorbidity care (eg, cardiology); genetic counseling; supportive care (psychosocial therapy, nutrition, occupational therapy, etc); palliative care, disease management (eg, from a health plan), and others. To add complexity, the care domains often exist within different care settings, organizations, and geographies. A patient may receive surgery in an academic institution, radiation treatment in a local hospital, and adjuvant chemotherapy in a local private oncology practice. Each domain serving a cancer patient may create a care plan, but there is rarely one integrated plan, and care decisions are often not aligned across domains. This often leads to costly duplicative tests, care delays, extraneous administrative efforts, and lost productivity for patients in their workplace and/or homes.
To have a sustainable and comprehensive impact on oncology costs, the care delivery and reimbursement models described by Dr. Eagle need to reflect the multidomain concurrency and develop cohesive pathways for the entire episode of care. While this appears to be a daunting task, we can leverage what has been learned from the existing multidisciplinary models in cancer care. Here we suggest a three-pronged approach for more comprehensive management of oncology care and cost containment.
First, evolve the current multidisciplinary models to support the multidomain concurrency in care. Multidisciplinary models[3,4] have been adopted in a number of large oncology centers to address fragmentation and disconnect between care domains, decisions, and care plans. These models are typically limited in three ways: they require face-to-face interaction, they are typically established within a single organization, and they often address only the diagnosis and the initial course of care, and not the entire episode of care.[5-7] These limitations may be overcome using systems-based approaches and information technology to improve coordination.[8,9] Recent technology advances allow for asynchronous and remote “virtual” team communication across time, entities, and organizations caring for one patient.
Second, develop a set of holistic pathways for the entire episode of cancer care, for patient subgroups. Advances in national guidelines, such as those developed by the National Comprehensive Cancer Network (NCCN), and information technology make this task possible. The full episode-of-care pathways will become the basis for developing a holistic care plan for individual patients. To account for the complexity of multidomain involvement, the care plan should be timed and sequenced based on all care events, including diagnostic and genetic assessments, procedures, therapies, interventions, and supportive care, with the ability to evolve into a survivorship or palliative care plan. The care plan is tailored based on several factors, including a patient’s detailed histological subtype, stage and grade of cancer; patient preferences, including the goal of care[13,14] (eg, to cure, extend life, provide palliation); best practices and guidelines; patient history; and comorbidities.
Third, a multidomain care team needs a team leader-a physician (assisted by an advanced practice nurse)-who is aware of all aspects of care for a patient and communicates virtually or directly with professionals involved in a patient’s care while serving as a touchstone for the patient. The current implementations of the oncology medical home assign this role to the medical oncologist. This certainly is appropriate for patients undergoing oncotherapy. However, someone should play this role during the earlier stages of oncology care, or for patients not indicated for chemotherapy. Either an earlier involvement of an oncologist as the “care team leader” of the medical home is needed, or other physicians (eg, surgical oncologists) could play the team leader role. The patient-centered plan must have incentives aligned to it; the largest incentives will come from payer reimbursement policies, which are a key factor in the success of any new model.[16,17]
Including the entire course of care in the efforts to improve quality and contain costs will make the short-term implementation more complex and perhaps controversial. However it will reflect the way that contemporary oncology care is delivered, and will allow for holistic care management and an optimization of cost. It may not be feasible to have any real impact on the full cost of oncology care until we plan for and manage cancer patients through their entire spectrum of care.
Financial Disclosure:The authors have no significant financial interest or other relationship with the manufacturers of any products or providers of any service mentioned in this article.
1. Siegel R, DeSantis C, Virgo K, et al. Cancer treatment and survivorship statistics, 2012. CA Cancer J Clin. 2012;62:220-41.
2. Lyman GH, Hauser RS. Optimal cancer care across the spectrum of life and disease. Am J Manag Care. 2008;14:262-4.
3. Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness. JAMA. 2002;288:1775-9.
4. Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness: the chronic care model, Part 2. JAMA. 2002;288:1909-14.
5. Bunnell CA, Weingart SN, Swanson S, et al. Models of multidisciplinary cancer care: physician and patient perceptions in a comprehensive cancer center. J Oncol Pract. 2010;6:283-8.
6. Gomella LG, Lin J, Hoffman-Censits J, et al. Enhancing prostate cancer care through the multidisciplinary clinic approach: a 15-year experience. J Oncol Pract. 2010;6:e5-10.
7. Chirgwin J, Craike M, Gray C, et al. Does multidisciplinary care enhance the management of advanced breast cancer? Evaluation of advanced breast cancer multidisciplinary team meetings. J Oncol Pract. 2010;6:294-300.
8. Reid PP, Compton WD, Grossman JH, et al, editors. Building a better delivery system: a new engineering/health care partnership. The National Academies Press Collection. Washington, DC: National Academies Press; 2005.
9. Clauser SB, Wagner EH, Aiello Bowles EJ, et al. Improving modern cancer care through information technology. Am J Prev Med. 2011;40:S198-207.
10. Galligioni E, Berloffa F, Caffo O, et al. Development and daily use of an electronic oncological patient record for the total management of cancer patients: 7 years’ experience. Ann Oncol. 2009;20:349-52.
11. McClure JS. Evidence and insights in the NCCN guidelines. J Natl Comp Cancer Net. 2012;10:427-9.
12. Aston G. Cancer care’s big leap. Genetic tests and personalized therapies are forcing oncology and pathology programs to constantly-and rapidly- evolve. Hosp Health Netw. 2009;83:30-2, 41.
13. Roenn JH. The “right” decision. J Support Oncol. 2012 Aug 30 [Epub ahead of print].
14. Smith TJ, Hillner BE. Bending the cost curve in cancer care. N Engl J Med. 2011;364:2060-5.
15. Schnipper LE, Smith TJ, Raghavan D, et al. American Society of Clinical Oncology identifies five key opportunities to improve care and reduce costs: the top five list for oncology. J Clin Oncol. 2012;30:1715-24.
16. Jacobson M, O’Malley AJ, Earle CC, et al. Does reimbursement influence chemotherapy treatment for cancer patients? Health Aff (Millwood) 2006;25:437-43.
17. Jacobson M, Earle CC, Price M, et al. How Medicare’s payment cuts for cancer chemotherapy drugs changed patterns of treatment. Health Aff (Millwood) 2010;29:1391-9.