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Institute of Medicine Recommends Measures to Achieve High-Quality Cancer Care

December 2013, Vol 3, No 8

In September, the Institute of Medicine (IOM) released its report, “Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis,” which included recommendations aimed at ensuring that there is accessible, affordable, and high-caliber oncology care in the United States for the foreseeable future.

But with the shifting fiscal landscape in the country, including the recent tussles of the government shutdown over Obamacare and raising the federal debt ceiling, as well as scheduled cuts to the Medicare Physician Fee Schedule, is it foreseeable whether the funds will be made available to achieve those laudable objectives?
Patrick Cobb, MD, who is president of the Community Oncology Alliance and was not a member of the committee that wrote the report, has doubts.

“The recommendations are going to require a significant financial investment by private payers, by government, by universities, by hospitals, and by private clinics—and with the fiscal environment we have now at the federal and state levels, I don’t think there’s going to be a financial commitment to making these things happen,” Dr Cobb, who is a hematologist in private practice affiliated with the St. Vincent Frontier Cancer Center in Billings, Montana, told Oncology Practice Management.

He also said that the report’s proposal to shift cancer care reimbursement away from fee-for-service to rewarding best practices will be “incredibly difficult” to accomplish. Others, however, are optimistic that a path forward can be found.

“We need to figure out ways to reduce costs and make effective treatments more universally available,” said Ismail Jatoi, MD, PhD, FACS, professor and chief of the division of surgical oncology and endocrine surgery at the Cancer Therapy & Research Center, The University of Texas Health Science Center at San Antonio, and also not a member of the report committee. “I think doctors can take the initiative and start the ball rolling with respect to things that are in the best interests of our patients. We can’t rely on government because they may not be able to do it.”

Ensuring Quality in the Face of Ballooning Demand
In 1999, another IOM report, “Ensuring Quality Cancer Care,” addressed gaps in providing ideal cancer treatment to every patient in the United States. Since then, however, the gaps have grown rather than shrunk. The annual cancer incidence has surpassed 1.6 million and the prevalence has reached approximately 14 million. At the same time, the cost of care rose from $72 billion in 2004 to $125 billion in 2010, and is on track to reach $173 billion within 7 years.
Meanwhile, the number of Americans who are 65 years of age and older is projected to double between now and 2030. This group will account for a large portion of the increased cancer burden, including diagnoses, deaths, and survivors. There will be 18 million cancer survivors in 2022, the authors of the new report estimate.

“We presented our report in the frame of a crisis—that if we don’t get our act together we’re going to be in deep trouble in terms of being able to deliver care the way we’re delivering it now to an increased number of patients,” Patricia A. Ganz, MD, director of the division of Cancer Prevention and Control Research at the Jonsson Comprehensive Cancer Center, University of California, Los Angeles, and the chair of the committee that wrote the report, told Oncology Practice Management. “We need to increase the efficiency, quality, and patient-centeredness of cancer care. Currently we have a very inefficient, uncoordinated healthcare system that’s driven by the fee-for-service environment.”

The way to accomplish this, according to Dr Ganz and the other committee members, is through a 6-pronged strategy aimed at attaining engaged patients; an adequately staffed, trained, and coordinated workforce; evidence-based cancer care; a learning healthcare information technology (IT) system for cancer; translation of evidence into clinical practice, quality measurement, and performance improvement; and accessible and affordable cancer care.

The report asserts that the main ways to achieve these objectives are:

  • Funding from government and other sources both to improve the development and dissemination of decision aids for patients that provide understandable information on all aspects of cancer care and to increase clinicians’ communication skills, and development of innovative payment models by the Centers for
  • Medicare & Medicaid Services and other payers
  • Improving end-of-life care via clinician training in end-of-life communication and more emphasis on palliative care, psychosocial support, and timely referral to hospices
  • Improving coordination be­­tween members of the cancer care team, eliminating reimbursement and scope-of-practice barriers to this level of coordination, and federal government funding of the National Health Care Workforce Commission
  • Ensuring that all cancer care clinicians have appropriate core competencies
  • Expanding the breadth and depth of data collected in randomized controlled trials and observational studies on cancer care for older adults and people with several comorbidities
  • Developing an “ethically sound” learning healthcare IT system that allows real-time analysis of data from patients with cancer in a broad array of care settings
  • Coordinating efforts between government and professional societies to develop a national quality reporting program for cancer care
  • Reducing disparities in access to cancer care for vulnerable and underserved populations
  • Increasing the affordability of cancer care by leveraging existing efforts to reform payment and eliminate waste

Can It Be Done?
“This is an ambitious list of goals. But there are none that don’t resonate with anyone who’s either a cancer caregiver or who has had a family member with cancer,” said Walter J. Curran, MD, Executive Director of the Winship Cancer Institute of Emory University, Atlanta, GA, and not a member of the report committee. He cited, in particular, the importance of making sure patients are provided with clinical and cost information associated with treatment options, and of expanding the breadth and depth of cancer research data. “This document has come out when there’s a federal shortage of research funding. But there are still research dollars; it’s a matter of how they’re prioritized.”

Drs Curran and Jatoi believe that the committee hit all the right notes, including the emphasis on increasing both the cohesiveness of cancer care teams and the understanding of how best to support patients in their choices of treatment.

However, Dr Cobb noted that only 1 member of the report committee represented community oncology: Michael Neuss, MD, who was in private practice in Cincinnati for 25 years before joining the Vanderbilt-Ingram Cancer Center in Nashville, Tennessee, where he is now a professor and chief medical officer.
Dr Cobb believes the report “is a very good place to start. But now comes the hard part—determining and implementing the individual steps that are needed to make the recommendations a reality, especially for a community oncologist in Billings, Montana, who sees 25 patients in his office every day. You’ve got to make things less complicated rather than more complicated. And that’s a real challenge.”

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