“Playing to the End”—As Valuable for Cancer Centers As for Sports Teams
Super Bowl LI reminded us all (regardless of which team you were cheering for) of a valuable life lesson. When you commit to something, you play each moment out until the end. That is all any of us can do.
Patients with cancer rely on us to be their guides, their champions, their team, and their partners. They are facing overwhelming individual challenges, which is sometimes all new to them, and unfortunately this may be a multipart journey for them. They have no idea that we ourselves are facing our own upheaval. The bedrock of wisdom and treatment on which they are relying is itself trying to provide the best care possible, in the face of financial obstacles for the provider and the patient, in the face of market competition, surrounded by increasing regulations and policy changes that threaten to reduce access and restrict medical decision-making, and most of all, to weather all that while launched, willingly or not, on a massive value-based reform tsunami.
It would be much easier if we didn’t have those challenges, but it would also be less rewarding. Oncology administrators, physicians, and the care team have to be the leaders in value-based reform, the forward thinkers, who look past the chaos for the open path. Value-based care is now being defined by many players, but only the people at the front line—the providers and the patients—are the true arbiters of value; however, we need information that we do not have.
Value will not be determined by the manipulation of the drugs and the treatment choices for services provided solely by cancer centers. We need to know more about patients with regard to their home situation, their comorbidities, and their support systems, and about the costs, treatment patterns, and choices of other care providers outside of our walls who also care for our patients, their follow-through, and their impact on our patients.
We are going to have to think beyond current technology. Electronic medical records were not designed to perform the complex analytics that we now require, to follow our patients through their care management needs, or to help us predict risk and population management. We are now looking, and will continue to find, assists and complementary solutions to fill those gaps, and to integrate with each other and the electronic health record for a better total picture. We must demand those solutions, and we must stand firm that when we find the answers we seek, we make it loud and clear that these are the variables needed to define value.
We Are the Quarterbacks
We are the cancer quarterbacks for our patients, our communities, and our country. We cannot allow short passes that only focus on the cost of one drug versus another, while ignoring the myriad other variables that could arise in a patient’s treatment, or in making changes to screenings and education that can move the curve of cancer treatment and detection from late stage to earlier stages, which is less costly in terms of lives and dollars. We need to factor into our choices our patients’ comorbidities, and complete the connections that bring their other care providers (eg, internists, surgeons, cardiologists) into our huddle. Historically, we have not been equipped to do that, nor have we often been provided the resources and support to do so. But sports teams have won games without the best equipment, or in adverse weather conditions, or against all odds, because they keep plowing forward 1 yard at a time.
On Super Bowl Sunday, during the second half of the game, I thought of our oncology community, the payers and employers with whom I work, the state and federal governments, pharmaceutical companies, and everyone in between. The oncologist or the cancer center may actually not end up being the quarterback (with the rise of accountable care organizations, integrated delivery systems, and clinically integrated organizations stepping in to create new playbooks and relationships), but we are nonetheless an integral part of a team. We want to be on the winning team, for our patients, for our continued viability in our chosen professions, and for society. No one wins when dollars are wasted needlessly. No one wins if targeted treatments that could change the future of cancer go unused because of financial, societal, or health-related barriers.
We need data, wisdom, forethought, and teamwork. We need to cross silos to communicate seamlessly for the good of the unit and the patient. I once had an oncologist tell me that he didn’t want to know the patient’s hemoglobin A1c levels, because then he would have to treat that disease as well, which was shortsighted and not a winning vision. I’m looking for an oncologist who can recognize the importance of knowing that a patient’s hemoglobin A1c levels, or something else, are out of the “normal” range, and then reach out to the patient’s other treating physicians so that the dots can be connected to maximize that patient’s health, even with the complication of cancer. Practices that are part of accountable care organizations and the Center for Medicare & Medicaid Innovation Oncology Care Model are learning these lessons a little faster than their peers, but not that much faster.
Every practice in the country is now subject to the Centers for Medicare & Medicaid Services (CMS) Quality Payment Reform Merit-based Incentive Payment System and Advanced Alternative Payment Models, and is monitoring their status on the Quality and Resource Use Reports (QRURs) from CMS. There are going to be some rewards, but there will also be penalties for the practices that fall outside of an “average” rating. For the first time, “average” is not measured against like-sized practices, similar specialties, or local geographies, and is still not a known quantity. No one knows what the future will hold, but we know that failure to consider the costs, factors, and other providers outside of the practice’s 4 walls will not result in “good” movement along the QRUR grid.
Be a Part of the Team
Smart leaders will learn to function as part of a larger team (legally integrated or not) and work from one playbook, regardless of their position on the field, and to assess all the variables that affect forward movement, not only those in their small section of turf.
Smart leaders will also take a deep breath, open their eyes to the bigger picture, and trust the other members of the team (eg, primary care, hospice, patient navigation, hospitals) to fulfill their roles, because they have put in the time to train together, communicate, huddle, evaluate all possible combinations and alternatives, and focus on the single collective goal of moving forward.
It is a tall order for oncology practices. We may have to find other smart leaders outside of the clinic walls, and support them as 1 cog in a larger team. It will take very slow progress against some heavy odds. We just saw, for better or worse, a Super Bowl won by a team that didn’t lead in score until the last second of the game. The end is what counts, and no one should give up until we reach that end. I am encouraged by so many people who are starting to change their thought processes and look outside of their walls, and to augment the skill sets they used to help grow oncology as a specialty and achieve all they have for millions of patients with cancer.
The old rules no longer apply; we have to be creative and find new paths with new partners. I believe we will make it to the end, but it will look much different. Coaches are just as important. We stay on the sidelines, but we add to the wider vision and we push our team members to strengthen their skills and partnerships, as well as their belief in the whole being more than the individuals.
I look forward to taking every step to the end through this new world with each of you. I know we will play to the end for our patients, for ourselves, and for society. We are not built to do anything else.