To many people, the question above may seem simple. But, there are many different answers, depending on the speaker’s perspective, and these are often contradictory. Some people say that physicians are best suited for interpreting and managing the care of patients with cancer. Others say that physicians do not have time to stay on top of new evidence and drug information, so oversight by external agencies and specialty pharmacies is necessary to ensure that appropriate decisions are made across the country.
?Yet other people fear that physicians may be making treatment choices based on the ubiquitous term “perverse incentives” rather than on “responsible choices” when given alternatives at a lower cost. Others say that larger entities are better positioned to mandate quality standards, either externally or by full employment of the physician. Some suggest that every patient is unique, and therefore the care must be tailored to provide the best hope for the individual patient.
?Yet others express regret that society can no longer afford to give everyone every possible chance, and that hard choices must be made by physicians, payers, or by someone else (it is harder to pin down who is willing to be that “someone else”). Among these are some who think that they can “out-evidence” the nationally accepted gold standard for the level of evidence and clin-ical consensus, the National Comprehensive Cancer Network’s Clinical Practice Guidelines in Oncology (NCCN Guidelines®) and the NCCN Compendium.
?Others are widely marketing their new ability to “manage” oncology spending from a pharmaceutical standpoint, or even for all costs within the medical benefit (including services and treatments in the physician office). From across the nation, employers, health plans, new collaborative entities, small to large oncology practice groups, hospital systems, and large academic centers bent on cornering the geographic market for cancer treatment are staking their claims to “managing oncology.”
?There is dissension even within the traditional oncology community. External pressures for health systems, payers, and providers to collaborate and build new accountable care organizations (ACOs), patient or oncology medical homes, integrated payer provider models, and independent physician associations have worked with consultants, lawyers, and meeting organizers, but so far these have proved to have little traction in the real world for oncology (with a few notable exceptions). Will physicians have the technology to adequately understand what is happening to their patients, and to actually manage the process, quality, scope, and value of care? Will it require the staffing and resources of larger entities? Will it require the additional support and resources of the major payers and even employers in the local area? Do we have the tools, knowledge, information, and sensitivity to the financial cost of treatment options for the patient but also for the payer, the employer, and for society as a whole? If not, are we collecting the right information to allow us to make comparative assessments for individuals, populations, and for alternatives to treatment?
?The answer to all these questions is yes, and no. This is the dilemma for oncology today, and for those who battle cancer and pay for it. We simply do not know enough, and that response is not acceptable to those who feel financial pressures and are searching for better control and for better answers to this puzzling disease.
?There are many challenges. Oncologists know the patient on a personal level. They and their staff of trained professionals make the difficult decisions, fight through the personal struggles, and deal with the physical and emotional tolls of the war on cancer in a way that no other entity seeking to “manage” cancer does. Oncology practices (whether private or hospital based) also have to deal with the financial realities of delivering the care that patients and their families require, in addition to figuring out how to cover their own costs in a timely manner, and how to remain open to provide care for patients.
?Our technology systems are still inherently lacking in the ability to track the elements of care and symptom management that we will need to adequately assess comparative effectiveness between different treatments. A physician practice or a hospital system is very capable of regurgitating for analysis what it saw and billed for in its interactions with patients; it is woefully blind to the additional costs and interactions that the payer may see occurring with the same patient. The payer is woefully blind to the clinical outcome of treatments and only sees what was done, not the details of a patient’s daily battle or success with cancer.
?External entities that seek to make oncology management decisions from outside the provider’s office are themselves blind to the individual patient and to the circumstances or health issues that have a daily impact on the management of a patient’s cancer. The only information that these entities have available is whatever is forwarded to them by the health plan or the practice; this is often not the full picture of medical care but merely a series of isolated snapshots.
?With all these blind spots in the perspective of any one of the entities seeking control of the management of oncology, it will be a wonder if we don’t stumble—if we have not already—in our previously steady progress in winning the war on cancer. What can we do in each of our own markets to contain and reshape this battle for the management of cancer? The following are 7 steps to keeping the patient and the physician at the forefront:
- ?Look outside your own 4 walls. Watch and listen to the regional and national markets around you: if lines in the sand are not already being drawn in your market related to management decisions for oncology treatment and payment, look where they are and learn; be prepared.
- ?Brutal internal assessment. How adept are you at truly managing the oncology patients in your practice, hospital system, and especially in your community? Are you limited by your data sources? Do you only know and track what happens to the patients for whom you care within your own clinic walls? What would it take to integrate a full profile of the care continuum for your patients to include what is done outside your walls? With whom do you need to interact and collaborate? What barriers do you need to hurdle? Are you applying and documenting a full care management program for your patients, so that you could review the entire patient population in the future and say, “What happened? What can I learn? What was effective, what wasn’t, and at what cost?
?Complete care management will of necessity integrate assessments, action, and tracking results. Health plans use care management as a documentation of HEDIS (Health Effectiveness and Data Information Set) and other quality management measures as a critical part of their business model. Are you tracking information that makes you a good partner for them?
- Understand the finances of cancer care. Some care providers believe that financial assessment of cancer treatments may begin and end with the cost of treatments used by their offices. Others counsel patients on the cost of treatments to the patient in terms of out-of-pocket costs under the patient’s benefit structure. Plans and employers, as well as society, consider the cost of treatments to be the total cost of medical services, drugs, and also the cost of hospitalizations, emergency department visits resulting from complications and side effects, comorbidities that may be a complication of one cancer treatment option selected over another, diagnostics, imaging, and other pharmacy and medical costs. Some providers are now working hand in hand with payers to understand those full costs and to identify what they can learn that may affect future choices. Some payers or pharmacy managers are focused solely on management of the cost of a drug at the time of treatment and do not recognize that there are a myriad of other issues that could make it more effective to choose a drug that costs more now to avoid significantly higher costs in the next weeks or months.
- ?Don’t get caught up in acronyms and the fad of the week. Quality cancer management is a lengthy process and requires a good deal of information. Collaboration outside of your own walls will be essential to closing the knowledge gap. It is entirely probable that many of the ACOs and external entities promising that they can manage oncology from outside the clinical walls will have dissolved in a few years. Linda Bosserman, MD, FACP, medical oncologist and President of Wilshire Oncology Medical Group, California, and her colleagues have focused on a strong data collection effort in their practice for decades, including tracking and evaluating what happens outside of their own care processes. Dr Bosserman has also built strong collaborations with the key health plans in her part of California, and she serves on policy committees for Blue Cross Blue Shield of California. This practice is now actively managing patients under full-capitation, partial-capitation, fee-for-service, and oncology medical home models. Dr Wasserman’s oncology group did not only talk about change, they actually did it. That change has led to documentable enhanced quality in care, and dollars saved, and a new perspective on oncology management between the practice, the patients, and the payers. It is not likely to find any external entities successfully inserting themselves between those physicians and payers; there is no place for them, nor did this oncology group have to rely on creating an acronym to define what they were doing. The Wilshire Oncology Medical Group just did it, and the acronyms caught up with them later.
?We have already seen too much reliance on the belief that if you build the “fad or acronym of the week” that “they will come,” and we have heard the response back, “it’s nice that you built it, but it’s too bad it isn’t what I wanted.” One team or committee does not speak for an entire market or country. Many external entities seeking to control oncology by co-opting subsets of physicians into support of a solution have floundered when it came time to roll out the program, and were surprised to find a lukewarm or negative reception outside the core group.
- ?Decide what you have to do, do it, and stay the course. Along the way, you may assess new relationships, new uses of technology, and new partnerships. There will be no one right answer; the solutions may end up looking different in various geographic regions of the country. Common sense will ultimately have to prevail. Short-sighted solutions that focus on drug price, creating an entity for the sake of doing what everyone else is doing, acquiring or selling out for reasons other than a well-defined strategic plan with careful positioning, or asking someone else to execute control of oncology choices without understanding what their agenda or value is will all happen, but fail.
- ?Don’t be afraid to ask for help. Seek out resources that may understand aspects of the environment or care continuum in a useful way for your own analysis. Effective oncology management cannot be done alone, no matter what role you play in the process.
- ?Be prepared for dissonance. Recognize that not everyone you talk to as potential partners, allies, or collaborators may be on the same page as you. You are more likely to run into the different perspectives about oncology management and how to do it as discussed at the beginning of this article than not. Figure out how you will approach and phrase your outreach, your messages, and your response to each perspective before you encounter it, and know how you will plan to move forward, even in the face of opposition.
?So what will the management of oncology look like in 3 years? I know what I would like it to look like, but this will take hard work, digging deep, and taking steps that may be completely unfamiliar to most of us. Many practice physicians and administrators are struggling to tread water in the face of an uncertain future. Patients with cancer will continue to need care, guidance, and treatment. It is up to you to decide whether you want to help shape your future, and in turn the future of patients who need you, or whether you will be content to let others shape it for you.
?My father lived by the philosophy, “If not you, than who?” He believed that if you expect others to step forward and take action for you, you are likely to be sadly disappointed, but you will then also deserve whatever you get. Consider the diverse perspectives now circling about how oncology should be managed. Do you have an opinion? Are some of those alternatives not acceptable? Then it is time to take action, and we need to step forward.