With Policy and Management, Are We Gaining or Losing Ground in the War on Cancer?

Dawn Holcombe, MBA, FACMPE, ACHE
President, DGH Consulting, South Windsor, CT

In 1971, President Nixon declared the war on cancer. Millions of dollars flooded into research facilities, and by the early 1990s, we reaped the benefits of those investments as new anticancer agents and supportive care drugs arrived to help us better manage the disease and its side effects. Cancer treatment rapidly migrated to physician offices designed as acute care facilities that allowed patients to receive cutting-edge care in a comfortable and focused environment, with highly trained, specialized professional staff and physicians leading the care teams.

Through the evolution of the community care model and the new arsenal of cancer treatments, patients found ways to integrate their treatment with their daily lives, often continuing to work and function as part of their families. However, rising prices on new treatments and increasing combination treatment options posed new questions about the clinical and financial oversight and management of the cancer treatment process.

It has not been easy for the clinical community to answer those questions and concerns, especially because the technological systems to support and track patient clinical care and status did not evolve as quickly as the treatment and, in many settings, still track only the basic information needed to process and administer a billing claim for treatment.

Many groups within the oncology community are starting to build technology solutions and data collection that will help us to answer challenges to medical treatment choices and the resulting patient outcomes. The nature of oncology is such that the US Food and Drug Administration (FDA) approves new drugs, but ongoing research and studies often discover applications for these drugs that extend beyond the initial “FDA label.” We have a strong culture and process for considering treatment options that are so-called off-label in relation to the original FDA indication, but have been established through oncology compendia and peer-reviewed literature to offer additional value in battling cancer since the first FDA approval of that drug. Payers and employers commonly express concern about needing better guidance regarding appropriateness of “off-label” cancer treatments, and more frequently challenge the care a physician might recommend as lacking sufficient evidence for approval to pay.

It now sometimes seems that we are embroiled in a race for control of medical decision-making and costs that could dramatically change the face of cancer care and the “war on cancer” in future decades. Although most treatments are still delivered in physician offices and outpatient centers, organizational relationships are changing. Increasingly, cancer care is delivered in larger, integrated settings (whether hospital-based or large group practices) that can serve to either enhance the sharing of clinical information and care parameters, or possibly increase the opportunities for communication gaps and possibly higher costs in more complex settings.
At the same time, we are pushing for better information systems to yield the data we need to improve our own internal oversight and management of cancer care, and some of the new delivery sites utilize legacy systems with more limited oncology specialization than previous sites possessed. Many hospital-based systems are notorious for multispecialty capabilities with little strength in oncology-specific needs, which can create integration and management difficulties when formerly private oncology practices, with oncology-specific systems, are acquired.

Federal policy is increasing the pressure for the development of accountable care organizations that, although not yet focused on oncology, are geared to support patient support systems and infrastructures that are likely to break down traditional care “silos” and move oversight and clinical decision-making into a more collaborative team environment. This, in turn, may make it more difficult for the private physician practice to function independently, and it may very likely evolve into bundled payment reforms that will present challenges to a freestanding physician practice. Cost pressures and the reduction of variation to meet bundled payment restrictions could then lead to the shrinking of innovation in care and in treatment, and possibly even a reduction of innovation in research and drug development—the exact opposite effect created when President Nixon declared the war on cancer just 40+ years ago.

Oncology management and oversight are proposed by external companies in the specialty pharmacy and oncology guidelines markets, even management of care delivered in the medical benefit (physician-delivered care and drugs), not just the pharmaceutical benefit. At the same time, the oncology community is ramping up its own individual and collective forays into oncology management, monitoring, tracking, and reaching out to payers and employers for new relationships and negotiations. These external companies are also reaching out to payers and employers to offer a single point of contact and solution to the challenge of complex oncology management.

Will we resolve these information technology and data collection demands quickly enough to retain our ownership of the clinical management and decision-making for cancer care?
Will we collaborate across diverse healthcare organizations and agree on policy and standards for oncology management and delivery originating from the healthcare professionals who have specifically trained for oncology management in time to bring these clinically driven solutions to the table with payers and employers, without falling into the traditional differences of practice and opinion that could undermine our negotiating position and presence?

Will we be able to scale up on a more universal basis some of the projects and pilots that have been developed in recent years in the oncology community across organizations as diverse as outpatient centers and private oncology practices, leaving the competition between those groups to differences of geography and service but keeping agreement on process and clinical decision-making?

Or will we find ourselves, in the near future—no matter what our own organizational structure is—following the universal policies and approval mechanisms of an external vendor that has contracted with payers and employers to run the approval processes, collecting clinical data in support of authorization requests that is then housed outside of the patient medical record and used to justify future clinical decisions for similar patients?

Although many payers and employers would like to engage individual practices, cancer centers, or multiple representatives in the oncology community, these are large organizations with responsibility for millions of covered lives and contracts, only a fraction of which are from the oncology community. The more unified the oncology community is regarding clinical decisions and processes and “evidence” for treatment choices and alternatives, the harder it will be for payers or employers to embrace an external vendor solution that is likely to use different parameters and choices. The less unified we are, the more attractive single oncology policy and oversight services from an external vendor may be to the payers who are beleaguered by rising costs and pressures, even in a complex field such as oncology.

So, it may be important to consider how you relate clinically to other cancer groups in your area and in your state. Is everyone seeking their “own” solutions? Is everyone going individually to payers and employers with different proposals? The clinical decision-making process should be—but has not been—fairly consistent across the oncology community, and that variation has weakened our ability to advocate for our patients with payers and with employers. Your state oncology associations may prove very useful in housing these types of central clinical discussions across the diverse providers in the community.

There will always be competitive differences in service, access, and environment between the medical communities, but if we allow clinical decision-making processes to vary significantly, we are opening the door wide for external vendor solutions to be imposed on us. In the process, we may just start losing the war on cancer. If innovation and clinical advances are restricted by external company parameters on medical decision-making, a slippery slope may be created—one that will be difficult to slow.

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