Quality Care for Patients with Cancer

The interview featured in this article was conducted with Linda Bosserman, MD, FACP, at the 2014 conference of the Association for Value-Based Cancer Care.

Q: What are the main value-based concerns for oncologists in the United States?
Linda Bosserman, MD, FACP (LB):
Oncologists are very concerned that the treatments they give to patients are actually going to improve their health. As we learn more about the growing costs of cancer care and the burden of patient copayments, we’re looking at, “Do we really understand the full impact of the treatment we’re giving to patients?” That means the outcome as far as progression-free survival and overall survival, as well as toxicities, side effects, the costs of those, and the costs to the patient of the overall regimen.

Q: Should oncologists concern themselves with cost issues, or is this beyond their clinical focus?
LB:
In today’s environment, there is no way an oncologist can avoid understanding cost issues if we’re going to help our patients evaluate the regimens we’re recommending, the total treatment course, short-term and long-term toxicity, what the outcome is, and what their cost is going to be.

Q: Are you concerned with the level of copayment that is faced by many patients with cancer?
LB:
As an active clinical oncologist and practice president [Wilshire Oncology Medical Group, Rancho Cucamonga, CA], I can tell you that patients’ copayments are a daily issue that our doctors, our staff, and I deal with. Particularly, even in senior advantage plans, patients are being asked for 20% copayments on increasingly expensive regimens; for many this is unaffordable. It’s not just a chemotherapy, biologic therapy, or oral drug copayment. It’s copayments for visits and for multiple treatment courses that are really becoming unaffordable to patients. More and more of our patients are coming back and saying, “I can’t afford that regimen. What are the alternatives? What are the costs?” We as physicians have had to learn it. Our staff has had to learn it.

Q: What can and should be done to alleviate the cost burden on patients with cancer?
LB:
When you look at the growing burden of individual patients paying for cancer care, we need to come together as payers, providers, the pharmaceutical industry, the government, and ask, “Why do cancer patients have an unfair burden of copayments compared with other diseases, and what is a fair copayment for which treatments?” If we were an ideal world in a value-based system, we might have no copayments for things that were highly effective and increase cure, or markedly improve survival and quality of life. Perhaps as we got into further lines of treatment with lesser, even questionable benefit, there would be more responsibility on the part of the patient. There are many ideas out there, but we have to come up with a solution, because right now it’s becoming unaffordable for patients in America.

Q: There is a growing push toward involving patients in treatment decisions. Should this apply to oncology, or does the fact that cancer is often a life-and-death situation change the equation?
LB:
As an oncologist who has practiced for 35 years, and in the community where I really know my patients, when you listen to patients, you learn they want to be actively involved, they and their family, or a combination. Sometimes they appoint a family member, but they want to know the truth. They have marketing material, they go on the Internet, but they want to know from their doctor, “What is my health, what is my disease, what is the comprehensive treatment program, what can I expect from that short term and long term, and what will be my health outcome? Also, what is my copayment responsibility for this package?” In our practice, we have found it is essential that every patient who goes for individual chemotherapy teaching also has separate financial teaching. People don’t understand their health plans. They don’t understand their copayment responsibilities. They need to have a plan, think about that with their families, and make arrangements, or, when available, apply for copayment assistance.

Q: Is there one theme that underlies patient care no matter where it is delivered in the United States?
LB:
There’s one theme that ought to underlie everything we do. We in medicine went into medicine to improve our patients’ health, to use our scientific knowledge, our years of training (12-14 years for an oncologist), to work with our patients, meet their needs, educate them, and walk with them through the path of their treatment, whether it’s for prevention, cure, or end of life, to improve their health, or relieve their suffering. We have to get back to that as the main value.

Q: There is continued concern regarding the consequences of community practices being absorbed into hospital settings. How does the setting in which care is offered impact the quality of care?
LB:
We’re hearing a lot about this change in the care side for oncology patients. Traditionally, 85% of patients in the past 10 years in America have received most of their treatment in the community. It was the largest side of clinical research, often with academic partnerships, and often using academic centers for super specialty, tertiary, or quaternary care. With the financial changes, we saw across the country a third of practices out of practice last year, and I believe this year will be even greater. It’s very regional. In Southern California, I’m not sure there will be many practitioners left within 2 years. They’re going to join academic centers, hospitals, or systems. In the big picture, this could ideally become very beneficial to patients. If you look at the Kaiser system in California, which has 40% market share, it’s a completely integrated system. Between the pharmacy, medical benefits, physicians, surgeons, oncologists, radiation oncologists, supportive care, rehabilitation, hospice, and survivorship, it’s all integrated on behalf of that patient. We’re seeing several systems come together in some regional markets to compete with each other. Ultimately, a patient could understand the health outcomes, survival rates, quality of life, and cost in system A versus B or C. Right now, consumers have no way to know if the care they’re getting is in their best interest and for their best outcome.

Q: What are the key components of high-quality breast cancer care?
LB:
I have been a breast cancer specialist for many years; there are many components to breast cancer quality care, from the patient’s point of view, the health plan, and from the clinician. If you look at reengineering the care from day ­­1, when a woman is first diag­­nosed, is there someone to talk with her, comfort her, walk her through the system? Can she get into treatment immediately to begin dealing with whatever the aspects of her diagnosis are and get information about how she’s going to get through that, what her health outcome expectations would be, and what the treatment plan would be? It means, quoting the National Comprehensive Cancer Network, for most women, having a core biopsy, so, from day 1, they know whether they have cancer, as ­­well as the initial types and features of that cancer. Therefore, how can she put a team together of medical oncologists, surgeons, radiation oncologists, plastic surgeons, or others, to begin putting a comprehensive treatment plan in place? Then, I think high quality means you have someone to navigate, whether it’s a medical oncologist or a nurse navigator, who helps you walk through and coordinate your care, understand the costs, and have the psychosocial, emotional, and family support that’s critical to caregivers and to patients. This is especially true for women, many of whom are mothers, wives, and now in the workforce, who have other competing concerns besides just the treatment details. Then it ensures that every patient, with her specific diagnosis, has a personalized care plan, treatment for her disease, its features, and her priorities and preferences. Are they of childbearing age? Are they menopausal? Are they already having menopausal symptoms? Do they have bone loss? Do they have hyperlipidemia? How do we coordinate their overall health with their breast cancer treatment to achieve the best health outcome for that patient? Those are the quality metrics that patients want to know. If they have advanced disease, they want to know a team is going to help relieve their symptoms and help them with the emotional issues. If they’re breast cancer survivors, they have significant emotional challenges, concerns, and side effects that need long-term management and support, especially in the workplace, and that it’s supported by their clinicians.

Q: What can physicians and practice managers do to boost awareness and participation in clinical trials?
LB:
Our administration and team members promote clinical trials at the practice level. We also encourage patients to find out about clinical trials. In reality, the ClinicalTrials.gov website does not work well. I’ve done searches and tried to find active-treatment protocols for patients. It’s more complicated than patients can sort through themselves…then when you think you have active clinical trials, and you make phone calls, you find out that they’re not available. That system, as a core nationally, needs to be improved. As we educate patients about clinical trials, we find they’re very open to them, but they want the trial to be integrated into their health plan, into their treatment routine, and as close to home as possible. It’s a very important value to patients, but the system itself needs to be revamped, even though we’re making people aware of it at the practice level.

Q: What tips would you share with members of the patient’s healthcare team—nurses, navigators, physician assistants, nurse practitioners—to facilitate access to care for their patients?
LB:
Most of us, whether we’re in an academic or community practice, are working with a team approach: teams of medical oncologists, surgeons, radiation oncologists, plastic surgeons, and physical therapists, but also within our team in the practice. At the practice level we have secretaries who do intake, financial analysis, access, and authorization. We have medical assistants who enter data and talk to patients about medications and their vital signs. We have nurses who deliver chemotherapy. We have advanced practice practitioners, otherwise known as nurse practitioners, and physician assistants, the physicians themselves, and our administrators. We all work as a team and try to divide the work to improve access, discussion, education, and treatment for our patients. No one doctor can do all this, and the team approach is critical. That’s often a challenge to explain to patients and make sure they’re comfortable with the whole team being there to meet their needs.

Q: What are the advantages of Commission on Cancer accreditation? What are the disadvantages of not being accredited?
LB:
Accreditation is important as setting standards…. Hospitals use the Commission on Cancer to certify their programs. It has certainly encouraged community hospitals to put resources toward the work, elevating the work of tumor boards, the documentation, educational outreach for the community, having special cancer screening days in the community and at academic centers. While I think it’s important, I don’t think patients pay much attention to the level of accreditation. As the money has dried up at the community hospitals, I have seen a significant cutback in their willingness to put up funding for the certification that no one’s requiring. Setting standards is wonderful, so we can all be on the page together and try to do our best as teams, but it also has to have realistic funding.

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