Transitioning from Treatment to Patient Management: A Tall Order for Oncology Practices
Public and private payers are embracing the concept of healthcare reform. Part of that reform will include a movement away from payment for treating patients and toward “value” and “performance measures.” These terms, as many others, are defined differently, depending on the beholder.
Oncology practices manage patients very well. We have systems for onboarding new patients, for moving them through their treatment cycles, and for accompanying them through their transition to survivorship or to death.
We view practice improvements as the ultimate solutions, such as triage pathways to better manage patient calls or the creation of oncology medical homes to encourage patients to turn to us as the nexus of their care. But are we really addressing the change that is being asked of us?
There is only one “pot” of money available for care—from the payer, employer, or the patient—and that pot is shrinking. The healthcare system is being asked to do more, but at lower payment rates. The possibility of shared-savings is transient at best and is certainly not self-sustaining as a revenue model.
So, what could we be missing with regard to patient management as we respond with our practice improvement programs? Patient management in oncology has existed as a risk management and cost-containment tool in the payer world for several years. This patient management touches patients before, during, and after practice visits for treatment with various programs. These programs have reduced the total care costs, hospitalizations, and emergency visits, and have increased patient satisfaction. They have been funded by payers or by employers and have been conducted adjacent to physician services, but not as part of the physician practice.
As oncology practices move to meet the demands and expectations of public and private payers for health reform and performance, there is still dissonance between the oncology community perspective of meeting patient management expectations and the expectations of health plans and employers.
Patient Management versus Treatment
I spoke to a major employer last week whose company is surrounded by several large, well-known oncology practices that are well-respected in the oncology community for their leadership and innovation in oncology practice improvements, including oncology medical homes. This employer noted that he could not find 1 oncologist who was interested in managing the care of his employees with cancer in the way that he needed.
He shared a story of 1 employee who was continually treated and released for work by his oncologist. One problem was that no one had asked the patient what kind of work he did; the patient was physically incapable of resuming his work outdoors with complex high-voltage equipment, which required dexterity.
The employer noted that there was no communication between the patient and the physician regarding his family and work situation, his need and his employer’s need for workplace productivity, and options for care that would preserve the patient’s ability to work.
This patient needed to continue active work to maintain his benefits, which was especially important with the impending birth of a child in his family. To the employer, this patient received cancer treatment, but he was not managed well.
Patient management involves additional communication with the patient before, during, and after treatment. We can learn a lot from patient management companies that have been servicing payers for many years.
Patient management includes assessments of risk and function, which affect patients’ ability to tolerate and succeed with treatment. Most of our electronic medical records do not have places to record, document, and report on comorbidities; medications; herbal treatments; fall and nutritional risks; cognitive function; physical function; substance abuse; and multiple depression, anxiety, and stress measures.
We do not include home assessments, because these can include examining caregiver support, living and facility conditions, food availability and preparation, home safety, transportation, shopping, and emergency support. Our oncology systems do not collect data on the patient’s tolerance of treatments; nutrition and hydration deficits; exercise and rest patterns; physical and cognitive function; and depression, anxiety, and stress changes.
All these variables affect patient treatment, total cost, and outcomes, and should be part of full patient management. Our electronic systems are also not equipped to integrate all this additional information with other patient information and to develop risk assessments in preparation for risk-based contracting.
Transitioning to Better Processes
Over the next few years, the practice of oncology will change. Limited financial resources and guaranteed payment reductions will force the change. Oncology practices will start to assume risk for patients. We may evolve teams for patient care that employ several tiers of patient support. These tiers will free advanced care providers, such as physicians, to focus their time on the patients who are the most complex to treat.
We absolutely will evolve to include full patient management, as described above, in our practice routines. In the process, as we manage patients better and more proactively, we will be able to change patients’ behavior and risks before these result in a need for additional care. Patients will need less emergent care, and the stress and burdens on the care teams will likely improve.
The challenge right now is that if we rely solely on technology systems to add a few more clickable forms, and if we produce a few more reports to prove to the Centers for Medicare & Medicaid Services and private payers that we are providing patient care planning and navigation, we are simply moving deck chairs around on the Titanic. We will not get to the depth of the transformation in patient management that is needed to make a significant difference in outcomes for our patients and, by extension, for our own lives.
Improving treatment processes, answering triage calls better, and creating the framework of an oncology medical home are good, but transitioning from treatment to full patient management and moving outside the box of traditional care patterns will be game changers for everyone. I have seen this done well for oncology outside of the oncology practice, and I can only imagine how much better it will work when these processes are embraced and incorporated into the oncology practice.
This new perspective on patient management will change the responsibilities and perspectives of every member of the practice team. Some groups are starting this journey as they prepare for the federal Oncology Care Model program. I can’t wait to share their stories.