Patient Engagement in Oncology a Major Challenge in 2016

Dawn Holcombe, MBA, FACMPE, ACHE
Editor-in-Chief
President, DGH Consulting, South Windsor, CT
We have seen rocky years before, but 2016 will certainly be challenging in the oncology arena. In the past 10 years, the operating environment for oncology providers who treat patients with cancer has changed significantly. We have seen the rise of the Medicare Part D drug program, the creation of multiple payment reform platforms, the changing role of specialty pharmacy and pharmacy benefits managers in the oncology space, and dramatic changes on the parts of public and private payers in the way they approach and manage patients with cancer. We have seen enormous changes in how patients receive care, from higher copays and coinsurances to donut holes and tighter benefit design. The delivery of cancer care has shifted between differing sites of care, narrowing networks, and the rise of retail infusion clinics. Everywhere we turn, someone is challenging or questioning the healthcare choices oncology providers make or is seeking to “manage” them, whether through managing drug options or the medical benefit itself. At the same time, oncology practices have been very vigorous in trying to shape the picture of innovation and quality transformation from within our community through oncology medical homes, bundled payments, new certifications in specialty patient-centered medical homes, and the transformation of patient triage through the Community Oncology Medical Home (COME HOME) project funded by the Centers for Medicare & Medicaid Services (CMS) Center for Medicare & Medicaid Innovation (CMMI). A few private payers have pursued pilots with a handful of oncology practices. Despite all of this turmoil and innovation, we still do not have the answer to quality, cost-effective oncology care. Employers and patients are facing rising premiums and treatment cost burdens. At a time when those who pay for care are seeking reductions in total payments, the oncology drug pipeline is burgeoning. New treatments are invariably add-on costs to the standard-of-care treatment and are not cost-saving replacements for current therapies. We understand more about personalized medicine, biomarkers, and diagnostic testing than ever before, and yet we still cannot say with certainty that we can identify the right treatment for a patient the first time through such indicators. Payers are starting to look at cancer treatments with dread in anticipation of additional costs to a limited financial pool. Yet, physicians and patients still look at cancer treatments with hope, and those 2 perspectives have to be reconciled. In 2016, we will see more ranking of medical providers by the public and the private sectors. CMS is taking major strides to push forward with the transitioning away from fee-for-service payments toward alternative payment models. The challenge for providers is that although CMS is transformative, it does not always get the details right: the payment levels may not be sufficient, and no bonuses will likely be disbursed in any of these new payment models without offsetting the payment reductions for other organizations. In the first quarter of 2016, the 100 oncology practices selected will be announced for participation in the CMMI Oncology Care Model. Whether a given practice or a hospital participates, the Oncology Care Model promises to be a game changer for oncology care delivery. When providers sit around a table and change their conversation from “what is the best option for the patient” or “how can I prove that payment models should appropriately pay for the services I provide” to “how can we save Medicare 4% or more,” that represents a sea change in providers’ perspectives on the value of oncology care. Treatments will be more carefully evaluated for efficacy before selection, alternative sites of care will be more carefully considered, and the monitoring of and interventions with patients between visits will be enhanced to reduce the incidence of complex side effects and hospitalizations. In 2016, we will also see a rise in the regulation and enforcement of governing bodies, particularly in relation to pharmacy and drug handling. The US Pharmacopeia already has published Chapter 797 on the compounding and handling of drugs, and will publish Chapter 800 in spring 2016. The enforcement of private and hospital-based oncology practices’ compliance with these chapters will rise from many fronts. State pharmacy boards, state legislatures, research networks, and hospital and payer networks, the Occupational Safety and Health Administration, and the US Food and Drug Administration have each, in different parts of the country, already started requiring compliance. However, there are few resources available to practices that understand the oncology and the pharmacy worlds and can bridge both of these worlds to find cost-effective, workable solutions for compliance. They do exist, but they will initially be a challenge to find. Patients are the key to most of these challenges. In 2016, we expect to see a rise in patient engagement and the support and creation of additional resources. The second annual Oncology Guide to Patient Support Services from the publishers of Oncology Practice Management will prove valuable to practices and to the patients they serve in navigating the many support services available to ensure that no eligible patients are left without help in getting the treatment they need. Patient adherence to treatment in all settings will become a strong part of the new value-based oncology care equation. In 2016, we will see a tsunami of change and oversight, expectations, and valuations, and we will focus on value. Oncology practices of all shapes and sizes will face the same issues, and will need experienced and flexible leadership to navigate the solutions. Despite the challenges, it is exciting to be at the cutting edge of the transformation of healthcare. I am looking forward to traveling these waters with you, my colleagues, friends, and compatriots.

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