What Will It Take for Oncology Practices to Survive?
At the 2018 combined Association of Community Cancer Centers and Cancer Center Business Summit, a robust panel discussion focused on 4 key challenges currently facing oncology practices. These include the “big data” explosion, workforce shortages, clinical advancements, and payment reform.
Panel participants included Robert J. Green, MD, MSCE, Senior Vice President, Clinical Oncology, Flatiron Health; Michael Kolodziej, MD, FACP, Vice President and Chief Innovation Officer, ADVI Health; Brenda Nevidjon, RN, MSN, FAAN, Chief Executive Officer, Oncology Nursing Society; and Michael V. Seiden, MD, PhD, Senior Vice President and Chief Medical Officer, McKesson/US Oncology Network. Kavita Patel, MD, MS, FACP, of the Brookings Institute, moderated the discussion.
Dr Patel opened with a request for predictions about the future of oncology practices. Dr Kolodziej responded by suggesting that cancer care needs to change, and quickly, as proved by current demands for information and execution.
Does Size Matter?
Small practices with fewer than 5 physicians will not have the size or resources to succeed and do a good job of executing the new care delivery model, Dr Kolodziej predicted, adding that a captive population is clearly what the market is moving toward, out of necessity. In the short-term, he said, we will likely see what has traditionally occurred during these types of integrations.
“I just don’t see a universe in which small practices survive, as we move forward,” Dr Kolodziej said. He noted that he fully expects to see a future where all innovative therapies are on some form of outcomes-based contracting.
If outcomes-based contracting works, providers will be rewarded, but “for that to work, we have to have data, we have to actually be able to hold providers accountable to a certain degree of performance, because I guarantee you, if you cannot manage the toxicity of immuno-oncologic agents, you are not going to be my doctor, and you are not going to be part of my [provider] network,” Dr Kolodziej said.
As our knowledge evolves, he said, larger healthcare organizations are going to be critical in collecting the data we need. We will see enhanced partnerships between the innovators and the providers—collaboration for mutual benefit, to the benefit of patients and physicians.
Dr Patel then asked Dr Kolodziej if he had any examples of such successful contracts, and he honestly replied that he did not. She agreed that outcomes-based contracts are exceedingly difficult to develop, and that it may be a while before they yield any promising results.
Access to Cancer Care
Dr Seiden, who has recently become President and Chief Medical Officer at McKesson Specialty Health, is helping oncology practices evaluate clinical advancement challenges and opportunities, and preparing his workforce to navigate complex clinical decisions.
The evolving world of precision medicine and its role in oncology care has a lot more work to do. The question is not about how you use these technologies, but rather, what is the problem that needs to be solved, Dr Seiden posited. Think about the approximately 1.6 billion people diagnosed with cancer in the United States. For many of them, cancer is becoming a chronic disease.
“There is a big need for these patients, who might be treated for years—maybe a decade—to be treated somewhere close to home,” Dr Seiden told attendees.
The average office that is closest to these patients’ homes—even if they are being treated by one of the larger cancer groups—probably has 3 to 5 practicing oncologists at most. These physicians have to treat a wide range of diseases, so the question becomes how do you provide the right information to those clinicians, so that the care they deliver does not vary from what the patient may receive at a large, academic center further from home?
Dr Seiden outlined 4 challenges related to solutions to minimize the treatment gap:
- Maximum connectivity is needed with key laboratories, so that as much information as possible is downloadable by the treating providers
- Whatever is not available electronically is made available through other means, including offshore staffing or optical character recognition, so that as much data as possible can be uploaded into the practice’s electronic health record, and then used in the patient’s care choices
- Oncology practices need clinical pathways—not pathways that are limited to diagnosis and treatment, but full clinical pathways that begin before the diagnostic workup has even started, and that address what may be needed (eg, tests) through diagnosis, as well as treatment and follow-up
- Practices also need an updated clinical decision support system that can direct physicians to what they need to know in a world with ever-changing evidence and innovation.
Access to Clinical Trials
Access to clinical trials that are close to the office, if not in the office, is always a desirable option, Dr Seiden said. As oncology practices move toward these ideals, they may get as close to perfect as possible. If this happens, then oncologists may have the tools they need to advance and thrive over the next few years. Right now, he said, it is very challenging for a physician to function as a broad-spectrum specialist.
Dr Green cautioned that there is a disconnect between the needs or interests of physicians and the speed at which the varied technology vendors are able to address the changing requirements. As solutions are formed, there is a need for the affected physicians to be engaged and involved in the discussion.
Ms Nevidjon agreed that the providers need to be engaged, noting that nurses and physicians are now specializing in information technology. It is not enough to enter and collect data, she said. There is an emerging key role for those who can interpret the data and apply them to change and transformation.
The growing demand for quality measures in oncology is driving not only new jobs, but also a need for clarification, and perhaps consolidation, of an expanding number of quality measures from many sources.
Ms Nevidjon noted that even our current beliefs may be subject to interpretation. Although many people in healthcare believe that there is a nursing shortage, data suggest that we do not have a nursing shortage, but rather a misdistribution of nurses geographically, as well as their choosing different jobs outside of the profession, she said.
Transforming Cancer Care with Data
The panelists addressed their optimism about the likelihood of oncology practices surviving, aligning data and quality, and that transformations will occur in the next 5 to 10 years.
Ms Nevidjon is quite optimistic: members from the Oncology Nursing Society, she said, are talking about oncology practices that are already doing groundbreaking work to find real-time solutions to these challenges.
Dr Seiden is optimistic, but recognizes that this is a journey, and that science often builds a thirst for information and data. However, he says, there is too much money spent on healthcare that can be better streamlined, as we have seen in other industries with equally complex data challenges.
Dr Kolodziej is concerned that our discussions at conferences and in practice are losing sight of this all being about the patient, ultimately. There does not need to be a business case for every payer decision or every data collection source, he says. We do not need physicians to add more data clicks to their days, but certain basic expectations exist: if physicians do not have basic staging information that they can use in their notes, there is reason to question the future survivability of that physician.
Dr Green closed the session with cautious optimism. He reminded attendees that things can go from impossible to inevitable pretty quickly. Dr Green noted that a 1- to 2-year time frame for needed transformations is probably not feasible; instead, the suggested 5 to 10 years is more likely.