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NCCS Submits Comments to CMS on Oncology Care First Model

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Department of Health and Human Services (HHS)
The National Coalition for Cancer Survivorship (NCCS) submitted comments in response to an Informal Request for Information on the proposed Oncology Care First Model. This model was released by the Centers for Medicare and Medicaid Services (CMS).

The comments focus on concerns regarding adequate resources in the model to support high quality cancer care. The letter also identifies shortcomings in the model that could influence treatment choices or penalize practices if they are unable to remain in the model. “These potential shortcomings of the model must be addressed to ensure that the model meets its promise of fostering patient-centered care.”

Read the full comment letter below. View/download the letter in a new browser tab » [PDF]

Read more NCCS Policy Comments »

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NCCS Joins with Cancer Leadership Council to Outline Concerns Regarding New “Step Therapy” Plan

NCCS Concerned That Proposed ACA Rule Changes Could Raise Costs for Patients and Disrupt Treatment

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So Many Reasons to Save the Affordable Care Act

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For six years now, the Affordable Care Act (ACA) continues to successfully improve health care in America. It provided coverage to 20 million people, allowed young adults to stay on their parents’ insurance until 26, emphasized preventative care, and sought to address inequalities in care, especially for women. For cancer patients and survivors, the impact of the ACA cannot be overstated. It is providing new hope by making coverage more affordable, increasing access to more life-saving treatments, and reducing significantly the fear and anxiety felt by so many cancer survivors by eliminating pre-existing conditions and life-time coverage limitations.

Without question, as health insurance markets and insurers work through these changes, the cost of coverage remains high for many people and is impacting some small businesses. Measures in the ACA that seek to address these issues are often overlooked and critically important: innovations in payment and delivery reform that are working to fundamentally overhaul America’s health care system, seeking to improve the quality of care and reduce costs.

As an excellent article in the New York Times states, “the law is leading a transformation of America’s health care system. It’s a change that nearly everyone, Republicans and Democrats, agrees is desperately needed — and for it to happen, the relevant parts of the A.C.A. must be preserved. The transformation moves health care away from a fee-for-service model, which pays doctors and hospitals according to the number of procedures they do, toward value-based care, which pays based on what helps patients get better.”

Barbara McAneny, MD

Barbara McAneny, MD
CEO, New Mexico Cancer Center

Friend of NCCS, and speaker at our Fall 2016 Cancer Policy Roundtable (CPR), Dr. Barbara McAneny is also featured in the article. Dr. McAneny is the Chief Executive Officer at the New Mexico Cancer Center. “We treat a lot of poor people,” McAneny said. “Their biggest co-pay was when patients went into the hospital. And even if they didn’t get one of the bad infections or blood clots, every hospitalization resulted in lowered quality of life. There’s a lot we can’t control. But we could control whether we aggressively managed side effects of cancer and its treatment to keep people out of the hospital.”

Watch: Dr. McAneny’s remarks at the CPR where she highlights her approach called the Community Oncology Medical Home model (COME HOME), and the difference it can make in the life of an individual patient.

What I am seeing, as we look at that graph where practices are selling to hospitals, and the exact same care now costs us more in a society that cannot afford it, is that we have to act very soon. We have to get back to saying, how do we get the low-cost practices that can deliver the quality? How can we give those resources and tools to physicians so that they and their practices can take a practice and meet the needs of their individual community in a very cost-effective way?

Read the New York Times article, “A Bipartisan Reason to Save Obamacare” »

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NCCS Comments on CMS’s Proposed Revisions to the 2017 Physician Fee Schedule

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NCCS submitted comments to the Centers for Medicare and Medicaid Services (CMS) on the proposed revisions to the 2017 Physician Fee Schedule. Our comments noted our support for the Oncology Care Model, but acknowledged that only a minority of cancer care providers and cancer patients will be part of this model. Therefore, changes to the fee-for-service system to foster patient-centeredness are needed to improve quality of cancer care for Medicare beneficiaries.

We supported some specific changes that CMS proposed to recognize the time spent outside the in-person office visit and to reduce the administrative burden associated with using chronic care management codes. We believe that in these proposals, CMS has balanced the needs of patients with the burden on providers, and that increased utilization of the chronic care management codes will enhance care planning and care management for Medicare beneficiaries with multiple chronic conditions, including many cancer survivors.

Additionally, NCCS supported the comments submitted by the Cancer Leadership Council, which made similar points about the need to reduce barriers to providing care management services and using the codes that would reimburse for these services.

Our full comment letter is reprinted below.

PDF Download: NCCS Comments to CMS on the proposed 2017 Physician Fee Schedule »

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September 6, 2016

Andy Slavitt
Acting Administrator
Centers for Medicare & Medicaid Services
Department of Health and Human Services
Hubert H. Humphrey Building
200 Independence Avenue, SW
Washington, DC 20201

Re: CMS-1654-P, Revisions to Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2017

Dear Mr. Slavitt:

The National Coalition for Cancer Survivorship (NCCS) is a national organization representing survivors of all types of cancer in efforts to foster patient-centered cancer care, including in the medical home setting. We have focused on several critical elements of the cancer care system in our efforts to improve the overall quality of care. We believe that patients should begin their cancer care experience with a shared decision-making process. We also consider patient-centeredness a core element of quality care.

We have lent our strong support to the Oncology Care Model demonstration project, which holds promise for the coordination of care across episodes of care as well as coordination among all cancer care providers. We are especially pleased that the Oncology Care Model includes cancer care planning as one of the elements of care that Oncology Care Model practices must include in their medical home model. Care planning as defined in the Oncology Care Model will encourage patients to consider the goals of their treatment and will foster shared decision-making. These elements of the care process hold promise of improving the “patient-centeredness” of cancer care. For all of these reasons, we believe Oncology Care Model is an important test of the medical home in cancer care. We look forward to its implementation and to evaluation of care that is provided in the model.

Despite our enthusiasm about the Oncology Care Model and the lessons that may be derived from this demonstration project and then replicated, we realize that only a minority of cancer care providers and a minority of cancer patients will be part of this model. We would like to see access to cancer care planning and coordination for patients whose care is reimbursed through the fee-for-service system. These services, as we have stressed above, are critical to fostering patient-centeredness. As a result, we have for years recommended that a new Medicare service for cancer care planning be established. We have offered that recommendation through comments on Physician Fee Schedule updates for previous calendar years and have pursued other actions to establish such a service for cancer patients.

We have in past years expressed our support for establishment of the Transitional Care Management Code, the Chronic Care Management Code, and the Advance Care Planning Code, because these new codes represent important steps toward more effective care management and the delivery of patient-centered care. At the same time, we have urged the establishment of a code that would be specifically targeted to cancer patients and would ensure cancer care planning and management.

Cancer patients would benefit from care planning and management across the continuum of care. However, we note two occasions when these services might be provided with the potential for substantially enhancing the quality of care. After diagnosis and at the time of treatment decision-making, care planning and management services can help to ensure that cancer patients with additional chronic conditions have access to well-planned and coordinated care – care that is coordinated through the episode of cancer care and care that is managed across all medical subspecialists providing care. At the completion of active treatment, cancer patients with additional chronic conditions face substantial challenges in the monitoring of their health status and the coordination of multi-disciplinary care. Cancer survivors may face risks of a wide range of possible late and long-term effects related to their cancer and care treatment, in addition to the challenges of other chronic conditions. Timely follow-up care may be necessary to address these late and long-term effects and ensure high quality of life for cancer survivors after their cancer treatment.

Ensuring the appropriate utilization of the chronic care management codes holds promise of boosting the overall quality of cancer care for Medicare beneficiaries.

Improving Payment Accuracy for Care Management and Patient-Centered Services

In the proposed rule, the Centers for Medicare & Medicaid Services (CMS) stated:

“In recent years, we have undertaken ongoing efforts to support primary care and patient-centered care management within the PFS as part of HHS’ broader efforts to achieve better care, smarter spending and healthier people through delivery system reform.”
We support, with some reservations, the following provisions of the proposed rule that seek to improve delivery of patient-centered care.

  • Recognizing CPT code 99358, for prolonged evaluation and management service before and/or after direct patient care, first hour, and CPT code 99359, prolonged evaluation and management service before and/or after direct patient care, each additional 30 minutes. We believe that these codes, which seek to recognize the resource costs related to time spent outside the in-person office visit to care for Medicare patients, may improve cancer treatment and cancer survivorship planning and management. We hope that these codes will be utilized by providers who are spending substantial time outside the in-person office visit related to the planning and management of cancer care. We have received feedback from cancer care providers that the resources necessary to plan active treatment and to map out survivorship care options are not adequately recognized in existing codes.

  • Reducing the administrative burden associating with the chronic care management codes to remove barriers to billing for these services. Although, as noted above, we saw promise in the chronic care codes in connection with cancer treatment planning and survivorship care, we understand that they have not been widely utilized by providers of cancer care. The feedback that we have received is consistent with the conclusions of CMS regarding possible underutilization of chronic care management services, based on the number of eligible Medicare beneficiaries.

    We understand that the original standards for utilization of the chronic care codes were intended to ensure the proper utilization of the codes and were also intended to offer certain protections to beneficiaries receiving chronic care management services. However, if the standards for the codes are resulting in underutilization, cancer patients are not seeing any benefits from the codes.

    We would not typically support the changes in the consent requirements, the 24/7 electronic access to care plans, or the reliance on fax transmission of care plans to patients. However, in this situation, we think that CMS has balanced the needs of patients against the burden on providers seeking to use the chronic care codes. If this balancing of interests achieves greater utilization of the chronic care codes – including for cancer patients and survivors – it will have been a patient-centered revision of the standards for the codes. We encourage CMS to carefully monitor the utilization of the codes and especially to ensure that that there are conversations between provider and patient supporting patient consent for chronic care services. Patient consent is important because of the cost-sharing requirements associated with chronic care services.

  • Establishing a new G-Code to improve payment for visits that are considered initiating visits for chronic care management services. We believe there is some promise that the G-Code for initiating services will eliminate the potential for the initiating visit requirement to impede access to chronic care management.

We appreciate the opportunity to comment on the calendar year 2017 Physician Fee Schedule update proposal. We commend the efforts of CMS to enhance care planning and management for Medicare beneficiaries, including those with multiple chronic conditions.

Sincerely,
Shelley Signature
Shelley Fuld Nasso, MPP
Chief Executive Officer

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Read more NCCS Policy Comments »

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Guest Post by Diane Blum: Developing the Systems to Meet the Psychosocial Needs as Part of Comprehensive Cancer Care

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This post is part of our 20 Years Later blog series which examines progress in advancing the principles in the 1995 NCCS publication Imperatives for Quality Cancer Care: Access, Advocacy, Action, and Accountability (Imperatives). The tenth principle states that “The provision of psychosocial services must be safeguarded and promoted. Persons diagnosed with cancer should receive psychosocial assessments at critical junctures along the continuum of care to determine availability of needed support and their ability to seek information and to advocate on their own behalf.”

 

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Post by Diane Blum, LMSW

Twenty years later, the 10th principle of the NCCS publication Imperatives for Quality Cancer Care: Access, Advocacy, Action, and Accountability (Imperatives), is as critical and significant as it was in 1995. When it was written, it followed years of psychosocial research that demonstrated that cancer created an emotional crisis for patients and families. It followed a decade of increased patient choice in treatment, a shift to outpatient care with greater responsibility on the patient, and the rise of patient advocacy groups that brought attention to the diverse needs of people with cancer. CancerCare, an organization founded in 1944 to provide emotional support and financial assistance to anyone with cancer where I worked for two decades, had been addressing psychosocial needs for half a century at the time Imperatives was written. Nonetheless, twenty years ago, there were few structures built into the delivery of cancer treatment that helped identify psychosocial needs, much less address them systematically.

It is gratifying to write that in 2015, these needs have regularly been recognized and addressed.  For example, the Institute of Medicine (IOM) has issued several relevant reports, including the 2007 landmark report, Cancer Care for the Whole Patient.  The Commission on Cancer now mandates that cancer centers have screening programs for psychosocial distress.  Most recently, the new Oncology Care Model for Medicare beneficiaries assesses the percentage of patients who receive psychosocial screening and intervention at least once during a defined episode of care.

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Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs (2008 IOM Report)

The positive news is that providing psychosocial services as called for in the 10th Principle has been “institutionalized” and recognized as an evidence-based need. Unfortunately the country has a significant shortage of mental-health providers, and there are insufficient resources to meet these needs. CancerCare and other support organizations in the oncology community fill crucial gaps by providing a wide range of counseling, education, and referral services, especially for the large majority of patients treated in settings without access to affordable psychosocial care. To extend these services, patient-centric support organizations need to work with one another and with oncology leaders to increase the number of community-based psychosocial practitioners and to develop more systematic and efficient links with medical care providers. Strategies to strengthen tools to identify patient needs as well as mechanisms to refer survivors to appropriate resources can be a goal for support organizations and health care teams to achieve collaboratively.

Patient advocacy groups and oncology thought leaders must maintain the energy that led to the NCCS Imperatives and the subsequent changes in practice. Now that we recognize and accept psychosocial needs as part of comprehensive cancer care, we must move forward to continue to develop systems that relieve patients and families of their psychosocial burdens.

About the author: Diane Blum, LMSW is senior vice president for Social Services at the National Executive Service Corps (NESC). She was executive director of CancerCare for 20 years until 2009 and CEO of the Lymphoma Research Foundation from 2009-2013. Ms. Blum served on the Board of Directors of NCCS for seven years and was editor in chief of Cancer.Net until 2013.

The views & opinions expressed in any guest post featured on our site are those of the guest author and do not necessarily reflect the opinions & views of the National Coalition for Cancer Survivorship. Read our blog and comment policies here.

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NCCS Submits Letters, Joins Cancer Leadership Council and C-P Alliance, in Comments to CMS on Proposed Revisions to Medicare Physician Fee Schedule

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NCCS submitted letters to the Centers for Medicare and Medicaid Services (CMS) on its proposed revisions to the Medicare physician fee schedule for calendar year 2016. In our letter, NCCS commended CMS for its efforts to enhance comprehensive care management for certain Medicare beneficiaries.  Through improvements in fee-for-service payments and various demonstration initiatives, CMS has made important strides in enhancing quality of care for many Medicare patients. NCCS strongly supports the Oncology Care Model, a demonstration project to be launched in 2016, because it will improve the care experience of cancer patients and will also foster the transformation of participating practices into patient-centered medical homes.  We have also lent our support to establishment of the transitional care management (TCM) and chronic care management (CCM) codes as these new payment reforms encourage care management.  We offered advice about additional improvements to fee-for-service payment through a separate Medicare service for cancer-care planning and coordination, which could enhance the quality of cancer treatment decision-making and overall quality of care. In addition to our own comments, NCCS signed a letter with other members of the Cancer Leadership Council about cancer care planning and coordination.

Finally, NCCS signed a letter with members of the Consumer-Purchaser Alliance (C-P Alliance), a collaboration of leading consumer, labor, and employer organizations committed to improving the quality and affordability of health care through the use of performance information to guide consumer choice, payment, and quality improvement. The C-P Alliance urged CMS to include consumer and purchaser priorities into the existing payment and reporting programs. Specifically, the groups urged CMS to pursue development, collection, and reporting of high-value measures of clinical and patient-reported outcomes; to require reporting clinician performance at the individual level; and to reward clinicians who deliver high quality and appropriate care efficiently.

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Guest Post Series: Dr. Michael Ybarra Offers Innovator Perspective on Oncology Care Model

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The Centers for Medicare and Medicaid Services (CMS) recently announced the Oncology Care Model, a new payment model for physician practices administering chemotherapy that aims to provide higher quality, more highly coordinated oncology care at a lower cost to Medicare. This week, we’re presenting several different perspectives on the Oncology Care Model and how it will impact patients, providers, and cancer therapies. Dr. John Cox also shared his thoughts earlier this week, as did NCCS CEO Shelley Fuld Nasso. Dr. Michael Ybarra, Senior Director, Alliance Development, PhRMA is the author of this post.

New Approaches to Paying for Cancer Care Will Benefit from a Patient Advocacy Perspective

The words “you have cancer” strike fear into our hearts. For patients, that news is often followed with emotional discussions of treatment options and confusing insurance lingo, which adds to the enormous stress patients and their families already suffer with a cancer diagnosis.

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Post by Dr. Michael Ybarra, Senior Director, Alliance Development, PhRMA

With an emotional diagnosis like cancer in particular, patients want to rest assured that they are receiving the best, evidence-based care and have access to clear information about their treatment. Insurers and health care providers are experimenting with new models of care with the aim to improve quality and reduce the costs of cancer care. Medicare is now testing several of these models through its Center for Medicare and Medicaid Innovation (CMMI), including a recently announced model for cancer care. While these reforms have the potential to generate savings and improve quality, there is also a risk they will reduce quality and access to treatments. Patient advocates need to engage in the development and assessment of these models to ensure they support the high quality individualized care for patients.

Earlier this year, CMMI began developing the Oncology Care Model for Medicare as part of the federal government’s goal to transition Medicare payment from fee-for-service to “alternative payment models” or “value-based payments.” In our current health care system, doctors are paid based on what they do, or “fee for service.” If a physician sees a patient in the office, and he or she does a procedure, they get paid for performing that procedure. Alternative payment models instead seek to pay providers based on the quality of care they provide and its cost.

Thanks to the advocacy of groups like the National Coalition for Cancer Survivorship, the Oncology Care Model includes several requirements that are intended to improve patient experience in cancer care. These include requirements designed to promote care coordination and keep patients out of the hospital, like providing access to a clinician 24 hours, 7 days a week and designing care plans according to the standards endorsed by the Institute of Medicine. However, there is still work to be done to ensure that the aspects of the model that are designed to reduce the cost of cancer care also support better care for patients.

“One of the challenges with this approach is that each patient is different, and CMMI will be setting cost benchmarks with only limited information about the type of cancers treated by the practice.”
CMMI’s new Oncology Care Model will still pay physicians fee-for-service, but with incentives to reduce the cost of care. When a cancer patient starts chemotherapy, a six month “episode” would be triggered. During the episode, the doctor will be paid an additional $160 per month for care management to support the enhanced services they are required to provide, like 24/7 patient access. Over the course of treatment, they will also be eligible for bonus payments based on their ability to reduce the cost of care during the episode.

One of the challenges with this approach is that each patient is different, and CMMI will be setting cost benchmarks with only limited information about the type of cancers treated by the practice. Oncology is a rapidly evolving field, and research shows that many cancers are different on a molecular level. New precision medicines increasingly allow us to target treatment, but what works for one patient may not work for another. Cost benchmarks will need to be flexible to recognize these differences.

The short, 6 month window to achieve savings also raises some concerns because physicians will have limited tools at their disposal to reduce costs and will only get “credit” for reducing costs in the episode, not in the long term. For example, if a new drug comes to market that’s twice as expensive as the old drug but it’s potentially better, the doctor may choose not to prescribe that one because the cost is higher. Ideally, the Oncology Care Model would be designed to accommodate advancements in cancer care and recognize oncology practices that make changes that improve their patients’ quality of life over the long term.

Medicare’s new Oncology Care Model is an experiment, and several questions remain about how the model will work and what the impact will be on patient care. The decisions that CMMI will make as it finalizes the Oncology Care Model over the next few months will have implications for patients, and we want the patient voice to be heard. We applaud groups like National Coalition for Cancer Survivorship for their advocacy on this issue, particularly around care coordination and patient involvement in decision making on new policies. As Medicare tests and evaluates the OCM, continued involvement by patient advocates is critical to ensuring that reforms balance patient access, quality, and cost control.

About the Author: Michael Ybarra, M.D. is a board-certified emergency physician and Senior Director of Alliance Development at PhRMA. In his capacity at PhRMA, Dr. Ybarra leads alliance outreach to provider, multicultural, and LGBT organizations. His issue areas include communications with health care professionals and delivery reform. In addition to his work at PhRMA, Dr. Ybarra works clinically in the Emergency Department at MedStar Georgetown University Hospital. The views & opinions expressed in any guest post featured on our site are those of the guest author and do not necessarily reflect the opinions & views of the National Coalition for Cancer Survivorship. Read our blog and comment policies here.

 

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Guest Post Series: NCCS CEO Shelley Fuld Nasso Offers Advocate’s Perspective on Oncology Care Model

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The Centers for Medicare and Medicaid Services (CMS) recently announced the Oncology Care Model, a new payment model for physician practices administering chemotherapy that aims to provide higher quality, more highly coordinated oncology care at a lower cost to Medicare. This week, we’re presenting several different perspectives on the Oncology Care Model and how it will impact patients, providers, and cancer therapies. Be sure to read the perspectives from Dr. Michael Ybarra, Senior Director, Alliance Development, PhRMA and oncologist Dr. John Cox. 

This month marks the 50th anniversary of the Medicare program. There has been significant press coverage of the Medicare program over the last 50 years, and a study published in JAMA yesterday reported strong improvements in care for Medicare beneficiaries in a number of areas.

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Post by NCCS CEO Shelley Fuld Nasso, MPP (pictured at 2014 NCCS event)

Given that half of all cancer diagnoses are in individuals age 65 or over, the Medicare program is critical to the delivery of quality cancer care for Americans with cancer. However, the current fee-for-service does not promote patient-centered, well-coordinated care, as Dr. John Cox eloquently described in his recent blog post.

We believe that it is essential to change the way we deliver care to cancer patients, and in particular, to improve the doctor-patient discussion about treatment options to ensure that patients’ needs, values, and preferences are considered in decision-making. In order to change delivery, we must change the way we pay for care.

NCCS has long advocated for a thorough, patient-centered cancer care planning process, at diagnosis and at major transition points in care, including the transition to survivorship. Patients need and deserve a care plan that outlines their treatment and post-treatment care. It’s not about checking a box that a piece of paper was handed to a patient – it’s about truly engaging patients in decision-making about their care; ensuring that they are informed about their treatment options, including both benefits and risks of treatment; and respecting their autonomy to be involved in decisions to the degree they wish to participate.

“The Oncology Care Model (OCM) begins to address these disincentives in the system by encouraging practices to transform the way they deliver care to be more patient-centered.”
In order to deliver this kind of care, physicians need time to spend with their patients. If you ask patients what they want and need from their care, and how they define quality care, they want TIME with their care team. They want to be seen as a person, not a tumor or a diagnosis or a case. The current system does not support this kind of care delivery. In fact, it provides strong disincentives for physicians to spend the kind of time that individuals facing cancer need during the most difficult time in their lives.

The Oncology Care Model (OCM) begins to address these disincentives in the system by encouraging practices to transform the way they deliver care to be more patient-centered. Key elements include the requirements for care planning, 24/7 access to physicians, and care coordination and navigation. It is not a perfect model, but it’s an important start. NCCS has been outspoken in providing a patient perspective on this important proposal and has shared comments with the Center for Medicare and Medicaid Innovation (CMMI).

We believe the OCM holds significant promise of boosting patient satisfaction and improving the overall quality of care, and we look forward to continuing to engage with CMMI through the implementation and evaluation of the model, so that we can learn from it and help disseminate the best practices and lessons learned.

As we celebrate 50 years of Medicare, we must not lose sight of the need to improve the way we care for our nation’s seniors with cancer.

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Guest Post Series: Dr. John Cox Offers Physician’s Perspective on Oncology Care Model

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The Centers for Medicare and Medicaid Services (CMS) recently announced the Oncology Care Model, a new payment model for physician practices administering chemotherapy that aims to provide higher quality, more highly coordinated oncology care at a lower cost to Medicare. This week, we’re presenting several different perspectives on the Oncology Care Model and how it will impact patients, providers, and cancer therapies. Be sure to read the other perspectives from Dr. Michael Ybarra, Senior Director, Alliance Development, PhRMA, and NCCS CEO Shelley Fuld Nasso.

Why are you doing this?

I have heard that question multiple times over the past months as I pressed our practice and institution to participate in the Center of Medicare Medicaid Innovation’s Oncology Care Model (CMMI OCM).   On first read some maintain ‘we are already doing this’; others, with closer inspection of the requirements and asks of the program, note ‘we can’t do this’.

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Post by Dr. John Cox, Medical Director, Oncology Services, Parkland Hospital (Pictured at 2014 “Putting the Cancer Patient First” event co-hosted by the American Enterprise Institute and the National Coalition for Cancer Survivorship)

Our current oncology care delivery models reflect the needs and priorities of the practice (regardless of site: private, institutional, or academic).   These models demand a lot of patients, yet often have a tin ear to patient’s needs or their voice.   Patients are given instructions on where & when to come – restricted to certain days or hours.   They are told what to bring, including a depth of information that they have provided to multiple others in the health system over the prior weeks.   Often they are asked to obtain records, images or pathology that were gained in other settings – indeed sometimes the very appointment they seek is dependent on obtaining these data elements for the oncology practice.

Contradictions in expectations continue once the patient is ‘in the door’.   Patients are told to be prompt (“Practice policy: patients may not be seen if they are 15 minutes late”) yet often patients will spend over an hour waiting – sometimes without a note of recognition.     Universally patients are asked for proof of insurance at each visit yet we often don’t address whether they are in pain or depressed.   Access to the office is “managed” by phone systems with greetings explaining a bewildering phone tree and always leading with a declarative statement which imparts the message: ‘if you are ill, don’t bother us, go to the emergency room’.   Contacting the office via phone often entails leaving a voice mail (another phone management tool) – though this must be done early in the day as the message notes calls will be returned before the end of the day, unless ‘received’ after 3 PM – then it will likely be the next day before the patient will get a return call and by the way if this won’t do – ‘go to the emergency room’.   With staff ever rushed, conversations are often had with patients facing our backs – we are talking to the screen in front of us – clicking thru required boxes.     Patient information and education is delivered via clipped conversations and the imparting of a stack of drug sheets explaining toxicities and decisions to come – and often a list of practice ‘policies’.

Oncology is amidst a revolution of the science that underpins the care we provide to patients. Indeed new approaches provide better definition of the diseases we treat and outline new and more specific therapies. We are seeing the fruits of better understandings of the genomic backbone of cancer.   YET, how we deliver care in a timely, efficient way remains as thorny, complex puzzle as the disease itself.

Why is care delivery so difficult?   Why is it not easier to re-structure how we work to better address patient’s needs?   A truism is that care delivery is structured to align with the payment system.   Restating a business adage: structure will ‘value what is valued’.   Our current system reflects the ‘values’ in the system: volume-based payment, payment that is guided by accounting to a set of billing codes that are, in turn, connected to very prescriptive ‘documentation guidelines’, AND the influence of other regulatory layers – all initiated for a good reason – but the weight of the whole force attention to detailed check boxes that result in a ‘clean claim’ rather than the patient occupying the room.   No practice can ignore these details, to do so fulfill the adage: ‘no money, no mission’.

Patients and physicians are frustrated.   In any gathering each can recount stories that illustrate the broken system. Each tells those stories through their lens.   For the past decade we have heard of experiments in care delivery that try to ‘wed’ the views – to give voice to concerns of both patient and provider.   These efforts include a few practices that remove themselves completely from the insurance system of payment & regulatory underpinning to provide very personal ‘concierge care’ to the elite. Others have tried to bring systematic practice change built around patients’ needs whilst at the same time identifying potential areas of cost savings.   These oncology medical homes have struggled to make the necessary investments to change practice structure while still being beholden to a fee-for-service (FFS) world, but several are beginning to show promise.   Other large practices, health systems and payers are forging complex relationships to build oncology-specific accountable care organizations – with a focus on patients and care delivery outside of FFS methodologies entirely.   Many hybrids and variations of these models are in play, though until now they have been relatively small pilots.

“Why is care delivery so difficult? Why is it not easier to re-structure how we work to better address patient’s needs?”
The Center for Medicare and Medicaid Innovation’s (CMMI) Oncology Care Model (OCM) draws upon the principles of oncology medical home to construct a more complex ‘value’ proposition than FFS.   The model will value the patient voice and force the practice to listen. Indeed many of the principles of the OCM are designed to infuse the patient perspective into the structure of the practice.   The model is not easy.   It is the exceptional practice that can claim to meet the six priorities outlined in the model or report on the various metrics it demands.     Addressing effective patient engagement, navigation and coordination of care goals defined within its principles will change how participating practices deliver care.

It is not a perfect model.   It is not a finished model, though it will press us to change.   We cannot hold to the past – as comfortable and familiar as those mechanisms of care are to us – we must embrace change, and try new ways of caring for our patients. Our science embraces experimentation and change – now our practices must.

About the Author: John V. Cox, DO, MBA, FACP – After more than 20 years in private practice, in February, Dr. Cox joined Parkland Hospital in Dallas as the Medical Director of Oncology Services. He completed a fellowship in medical oncology and hematology at the University of Texas Southwestern Medical School. He completed an MBA, with a certificate in medical management from University of Texas Dallas in 2008. He is an active leader in his hospital medical staff at Methodist Hospitals of Dallas and his group practice. He is active in the Texas Society of Clinical Oncology, and is the Texas oncology representative to the Texas Medicare Carrier Advisory Committee of Trailblazer. He served as a member of CMS’ Medicare Evidence Development & Coverage Advisory Committee from 2006 to 2010. Dr. Cox is active in ASCO and is a member of the Clinical Practice Committee, which he chaired from, 2005-2006. He has served on the HIT/EHR Workgroup since its formation in 2005, and is this group’s immediate past-Chair. Beginning in January of 2009, he became the editor and chief for the Journal of Oncology Practice (JOP). He serves as ASCO’s representative to the American College of Physician’s Council of Subspecialty Societies and serves on that body’s workgroup dealing with Patient Center Medical Home & has helped develop policy related to the role of specialty practices within the PCMH Neighborhood. The views & opinions expressed in any guest post featured on our site are those of the guest author and do not necessarily reflect the opinions & views of the National Coalition for Cancer Survivorship. Read our blog and comment policies here.

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WCOE: Touching Tribute in Memory of Chris Tannous, Paying for Cancer Treatment, A Life-Saving Second Opinion, and the Underbelly of Medicine

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What Caught Our Eye (WCOE) Each week, we recap the cancer policy articles, studies, and stories that caught our attention.

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WCOE: Patients’ Need to Be Advised, Confidence in Cost Communication, Compassion, and NCCS CEO Weighs in on CMS’ Oncology Care Model

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What Caught Our Eye (WCOE) Each week, we recap the cancer policy articles, studies, and stories that caught our attention.

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