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Building the Oncology System of the Future

February 2015, Vol 5, No 1

Practice managers, physicians, and members of industry gathered recently at the Cancer Center Business Summit (CCBS) to consider the state of cancer care delivery and its future. A panel discussion among key thought leaders featured perspectives from the oncology community as well as national policy advisors.

Paul H. Keckley, PhD, Managing Director of the Navigant Center for Healthcare Research and Policy Analysis, joined Allen S. Lichter, MD, FASCO, Chief Executive Officer of the American Society of Clinical Oncology (ASCO); Lindsay Conway, MSEd, Practice Manager of the Oncology Roundtable at The Advisory Board Company; and Gary H. Lyman, MD, MPH, Codirector of the Fred Hutchison Institute for Cancer Outcomes Research, for the discussion.

In his presentation, Dr Keckley shared that the pressure to reduce healthcare spending will not dissipate, even if reform is challenging, because costs and the growth of costs in healthcare continue to adversely affect the economy. There are examples of large systems (eg, investor-owned healthcare) that have fared fairly well since the passage of the Patient Protection and Affordable Care Act (ACA); these systems have not yet overtly addressed cancer care, but he expects that they will in the future.

The Patient-Centered Outcomes Research Institute, established through the ACA, has the potential to provide a substantial shift in the delivery of cancer care, Dr Keckley stated. The institute was charged with supporting comparative clinical effectiveness research that helps patients, caregivers, clinicians, employers, and insurers make informed health decisions. The open market is already responding with announcements of technical gadgets and a biometrics revolution of what we wear and how it interacts with us physically—representing a movement toward putting more health information directly in consumers’ hands.

Dr Keckley summarized with his vision that it is conceivable to have just 80 to 100 integrated health systems across the United States within the next 10 years, paid on a capitated basis, with responsibility for early disease detection as well as long-term care. Such a scenario would inevitably change the dynamics of cancer care.

Dr Lichter presented the initiatives that ASCO has considered to build the delivery system of the future. Solutions include at least 3 simultaneous revolutions: cancer panomics, big data, and the cost structure and valuation of health- care, with a possible fourth revolution related to patient engagement. He emphasized a growing recognition of treatment value (compared with cost only) as the primary driver for innovation in clinical practice. ASCO is actively engaged to move these revolutions forward, but it is not easy or fast to accomplish, he said. He also noted that in the future, the utility of treatment will be driven by real-time analysis of real- world data from active clinical care, rather than by clinical trials and research alone.

Ms Conway shared trends that the Oncology Roundtable has seen to be shaping community hospitals and cancer care. Patients will become more demanding and discerning healthcare consumers by 2018, she said, driven by new insurance plans, activist employers, new financial incentives, and growth in private health markets. Shrinking health insurance networks will exclude providers, and the providers who find themselves outside of or within key networks will have to find ways either to survive out of network or to conform to the greater cost sensitivities within them, respectively. Treatment decisions are likely to change as providers begin to stratify patients for management choices based on risk assessments.

In the northwest United States, the Fred Hutchison Institute for Cancer Outcomes Research, as a leading area cancer provider, has been involved in a regional collaborative network looking at cancer outcomes with 60 regional employer and plan stakeholders. Dr Lyman shared that from an initial list of more than 100 recommendations for factors to consider when studying cancer care outcomes, the network has narrowed those choices to a list of 6. These data will be tracked over the next year and benchmarked for adherence; he indicated that perhaps this approach could extend to other regions or nationwide. Currently, 2 specific interventions are moving forward: one involves capturing data before and after a patient-centered education campaign, and the other involves tracking the use of growth factors.

General consensus among participants was that major networks and growing systems of healthcare providers will transition treatment choices from individual physician–patient interactions to a more global care continuum focus. Increasing attention to the total cost of care will change discussions regarding the definition of appropriate treatments. Pathways, while continuing to emerge as an essential element in the growing process of care delivery, will serve as just one tool in the larger discussion of relative value, efficacy, total cost, and impact of decisions on care outcomes. Manufacturers of cancer care drugs will need to equip their teams with the ability to adapt to rapidly changing delivery leaders in individual markets, and to tailor materials and support for a variety of perspectives.

Some leaders in providing care will be more focused on the role of products in the total cost of the care continuum, whereas health plan decision makers and policy makers may request proof of value to the employer or plan to better meet the needs of insured patients. Increasingly, patients, treating physicians, and health plans are likely to ask manufacturers of new products for comparisons to other market alternatives and even to other delivery or site-of-care models that may be supported by the treatment options (home care, oral medicines, pumps, self-administration, or even decisions to not treat).

During an audience question-and­-answer session, one point summarized the status of the future healthcare delivery model debate: there is a need to innovate in drugs, but also to recognize that a focus on the cost of drugs, especially multiple combinations of drugs, comes with reduced sustainability of cancer therapy. All stakeholders need to come together to determine how to balance the needs of patients and providers with the efforts of the pharmaceutical industry and the concept of value. We do not, however, have any definitive answers yet.

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