What are the most noteworthy trends that can affect an oncology practice’s strategic planning, budgeting, and bottom line? The Association of Community Cancer Centers (ACCC) partnered with the Advisory Board Company to identify some of those trends in the 2017 Trending Now in Cancer Care Survey. The survey results were presented at the 2018 ACCC Annual Meeting & Cancer Center Business Summit.
Deirdre Saulet, PhD, Practice Manager, the Advisory Board Company, moderated a session at the ACCC meeting on key trends and strategic innovation in oncology practice. She discussed the results from the 2017 Trending Now in Cancer Care Survey and what they mean for oncology practice managers and providers.
A total of 291 providers responded to the survey—52% were from a nonteaching community hospital, 37% were from an academic medical center or teaching hospital, 5% were from an independent physician practice, and 4% were from a freestanding cancer center. The remaining 2% were from a Prospective Payment System–exempt cancer hospital.
According to Dr Saulet, the survey revealed 4 top trends that are most affecting cancer program strategies:
- The rates of cancer cases are increasing, along with a growing competition for cancer programs. Although new cancer cases in the United States are predicted to rise to 1.91 million by 2026 (up from 1.57 million in 2016), 19% of the surveyed cancer program leaders reported that competition has significantly increased for most cancer programs, and 39% reported that competition has slightly increased. On a more regional scale, 32% of the respondents from academic cancer centers reported that competition in their market has significantly increased in the past 24 months
- Reimbursement is at a turning point
- Patients with cancer are starting to act like consumers
- Precision medicine is revolutionizing cancer treatment.
Referral Process and Diagnostic Pathway Initiative
Jo Duszkiewicz, MSA, RN, Vice President and Administrator for Cancer Services, Renown Institute for Cancer, Reno, NV, discussed Renown Health’s Intake Oncology Coordinator Clinic as an example of strategic innovation in patient access to care in the face of these trends.
The Renown Health network includes 3 major area hospitals and provides transitional care (eg, rehabilitation, assisted living, home and hospice care), insurance services via Hometown Health (Nevada’s largest nonprofit health insurance company), and networked services (ie, more than 300 providers, primary and specialty care, lab and imaging centers).
The Renown Institute for Cancer is the largest cancer center in northern Nevada, serving more than 1800 patients. Through TeleHealth, Renown serves eastern California and Nevada with more than 30 specialties. However, despite strong communication and coordination, delays in patient diagnosis were caused by primary care physicians not knowing what diagnostic tests to perform, multiple calls being made to specialists for advice and assistance, and complex navigation through cancer workups.
The Renown team solution was to create an intake initiative led by an advanced practice nurse. This initiative standardized the referral process and diagnostic pathways, and the advanced practice nurses became known as the Intake Oncology Coordinators. A referral comes in to that coordinator, who gathers all the information and decides, with a sponsoring physician, whether:
- The patient needs to be seen by someone to go through the diagnostic process
- With review of the medical record, the primary physician can just be advised to provide a different referral or perform a test and stay within the primary care office
- They can just perform a medical record review and advise the patient and primary care physician to wait and follow up with a test in a few months, as a way to monitor the patient.
Since starting the program, the intake coordinators have spent approximately 31% of their time providing referral advice over the phone to patients and physicians, 25% of their time on chart reviews of referral requests that led to monitoring requests, and 44% of their time on calls that have led to clinic visits for referred patients. The program has grown significantly in 4 years. Referrals to the intake coordinators have seen a 49% increase, with a 45% increase in patient visits, and a 57% increase in returns with recommendations. In addition, chart reviews in which patients were referred for monitoring increased by 325%. Of the referred patients, 49% had cancer, and 38% had lung cancer.
One example was of a 75-year-old nonsmoking woman who was referred from a primary care physician after a positron emission tomography (PET) scan showed a 2.8-cm lung nodule. The patient was referred to the intake coordinator and a biopsy was performed 4 days later. The biopsy results showed lung carcinoma and were given to the patient within 1 week of the initial consult. PET scan results completed within 1 week and magnetic resonance imaging completed the next day were consistent with the findings of metastatic lung cancer. Radiation oncology and medical oncology referrals were provided when the staging was completed. Radiation oncologists saw the patient within 2 days of the referral, and the medical oncologists waited until 4 days after the referral to see the patient to have the staging completed.
“That is just one example of how you can quickly get the patient through the system with focused attention by one individual through the diagnostic process,” Ms Duszkiewicz said.
Reimbursement and Value-Based Contracts
Dr Saulet then discussed the mounting pressure on fee-for-service reimbursement, with the Centers for Medicare & Medicaid Services (CMS) recently reducing payments to hospitals under the 340B drug program, which includes reducing payments to nonexcepted hospital outpatient departments to 50% of the Hospital Outpatient Prospective Payment System rate, and using new drug administration packaging for select Level 1 and 2 drugs. Commercial health plans are also affecting hospital-based reimbursement by seeking to move infusion services outside of higher-cost hospital outpatient department settings.
One strategy to counter declining reimbursement is participation in value-based contracts. In the survey, 40% of the respondents said that they were participating in a shared-savings or an accountable care organization (ACO) model, 27% were participating in the CMS Oncology Care Model (OCM), and 32% were not participating in any value-based contracts.
Dr Saulet reviewed an example of an oncology-specific ACO of the Miami Cancer Institute at Baptist Health South Florida. It began in 2011 as a collaboration between the Miami Cancer Institute and a large regional payer. Originally, a private oncology group, Advanced Medical Specialties, was the third participant, but that group is now a part of the Miami Cancer Institute. The oncology ACO focuses on patients diagnosed with 1 of 6 cancer types, and relies on fee-for-service with spending targets and shared savings among the partners as long as certain quality metrics are met. This oncology ACO model confirmed that savings are feasible under such a model.
For 1006 patients, the per-patient savings were $354 in year 1, $2235 in year 2, $9095 in year 3, and is projected at $4917 for year 4—a total reduction of $4,280,924 in the payers’ total spending. Some of those savings are attributed to a >90% rate of provider compliance with oncology clinical pathways, but this could be because providers became more sensitive to payer spending because they knew they were being observed.
The next goal for the Miami Cancer Institute and the oncology ACO is to target admissions, emergency department visits, and unnecessary imaging and radiation therapy.
Growth of Cancer Programs in Jeopardy
Another major trend identified in the survey was looming threats to the growth of cancer programs. Of the survey respondents, 68% considered the cost of drugs and/or new treatment modalities the biggest threat to future growth. Less than 50% of those surveyed felt other issues were threats, including physician alignment around services and program goals, changes in health coverage, and shifting reimbursement away from fee-for-service to value-based care.
What do the 2017 trends survey respondents feel are the best opportunities for cost-savings? Approximately 67% said clinical standardization, and 62% said drugs could help cost-savings.
Mount Sinai Pilot Program
Mark Liu, Director, Strategic Initiatives, Oncology Service Line, Mount Sinai Health System, New York, discussed how Mount Sinai Health System developed a pilot program to move toward value-based oncology care by focusing on the clinical standardization opportunity.
Mount Sinai is an integrated heathcare system that covers the 5 boroughs of New York City, Long Island, Westchester, and Florida, with 7 New York–based hospitals, 12 ambulatory surgical centers, approximately 2500 full-time physicians, and more than 1000 affiliated physicians. The Mount Sinai Cancer Center—a National Cancer Institute–designated cancer center—has 9 hospitals with 126 infusion chairs, and accommodated 315,000 outpatient visits in 2017.
The Mount Sinai vision for transformation to value-based care includes the use of disease management teams, clinical pathways, and a chemotherapy council, as well as leveraging their Epic Beacon software. Their strategies for value-based care include enhancing their cancer network, contracting, inclusion of the Mount Sinai faculty practice associates and the independent practice association, and their involvement in the OCM.
Participation in the OCM provided the platform for expansion of quality metrics, care pathways, and furthering value-based care by determining systemwide best practices for the most common clinical scenarios. Currently, the disease management teams at Mount Sinai focus on several cancer types, including gastrointestinal, genitourinary, lung/thoracic, leukemia, skin, gynecologic, and sarcoma; they also provide supportive care. A Molecular Tumor Board is in progress.
A Chemotherapy Council was created with 2 primary goals—minimizing care variations in medical oncology by developing evidence-based chemotherapy order sets, and reviewing proposals or requests to change the current practice of medication prescribing, administration, and preparation. The Chemotherapy Council meets monthly with a quorum of 5, including nurses, physicians, and members from pharmacy and Epic Beacon. The council uses a regimen score sheet and point system to score potential regimens. Once approved, the order set is made available in their Epic Beacon technology within 1 to 2 weeks.
“By better understanding what our cost drivers are; what drugs are being used; how often patients are appearing in the emergency room—not just in our health system but locally, as well as admissions for patients—we are able to use this information to better focus our efforts on how we can develop our systems to better meet patient needs,” Mr Liu said.
Patients with Cancer as Consumers
Dr Saulet wrapped up the session by discussing the last 2 major oncology trends identified in the 2017 trends survey.
Patients are becoming more independent, which is disrupting traditional referral patterns. The Advisory Board Company research suggests that 3 primary factors are driving this patient consumerism, including a growing price sensitivity by consumers, increased access to healthcare information that they can use for their decision-making, and rising expectations for services and subsequent changes in the nature of the physician–patient relationship.
“We know that cancer patients already are doing their homework. In a 2015 survey we did of cancer patients, over 40% of those patients told us they had gone online to look at provider reviews or quality performance websites when they were selecting a provider,” Dr Saulet said, adding that the Advisory Board Company intends to follow up on their 2015 survey, and the expectation is that the percentage of patients reviewing provider information online will be much higher in the new survey.
How do cancer programs intend to differentiate their cancer programs with increasing consumerism? The 2017 trends survey respondents most frequently said that they intended to increase the number of subspecialists, including breast surgeons and gynecologic oncologists (59%), and to invest in more marketing to better reach (41%) and attract these self-directed patients. Patients varied in their interviews as to what they were looking for in a relationship with their physician.
At Sharp HealthCare, all physicians are given the opportunity to add a personal statement, phone number, and/or video to their profile on the “Find a Doctor” section of the Sharp HealthCare website to help patients in their search. Physician profiles that include photos are viewed twice as often as those with no images. Profiles with videos are viewed 3 times as often as those with no videos.
Precision Medicine Revolutionizing Cancer Care
As precision medicine and molecular testing become more common, company investment in oncologist support is critical. Almost all respondents to the 2017 trends survey noted that they are sending out biopsy samples for molecular testing. The most common tests were predictive assays (eg, Oncotype DX) and single-gene testing (eg, KRAS, EGFR, HER2). More cancer programs send samples out for small-panel (≤50 genes) testing than for large-panel (>50 genes) testing. Overall, 31% send samples out for whole exome/genome sequencing.
Three tactics that can help to support oncologists with precision medicine include providing infrastructure for clinical decision support, ensuring access to molecular tumor boards, and dedicating resources for ongoing support. Almost 30% of physicians responding to the 2017 trends survey reported that they were very uncomfortable with managing immune-related side effects.
Considering these 4 trends can help oncology practices and programs in planning for the future and determine how they are going to respond to forthcoming challenges.