This post was originally published by the American Journal of Managed Care.
While actively treating cancer patients for their malignancies, oncologists like to take full ownership of the medical care for their patients. Because so much of cancer care is highly specialized, this makes a lot of sense. But it is not unusual for lines of communication between doctors, doctors and patients, and doctors and family members to break down. Every oncologist has stories about missed handoffs. Every patient can recount, in excruciating detail, all the times their doctors did not make an important phone call. If we are aiming for the best patient outcome and the best patient experience, we aren’t even close to hitting the mark. And to my knowledge, no one is taking ownership of this problem.
This lack of care coordination will become a crisis as care moves to integrated delivery systems, like accountable care organizations (ACOs). The rationale behind these arrangements is that by forcing an organization to assume both clinical and financial responsibility, all of the interested parties will become engaged, as they will be at risk for a bad outcome. However, even a superficial analysis of how these programs are evolving reveals the obvious problem: specialists—who take care of the most complicated and most expensive (and, therefore, the most critical) patients—are marginalized. Additionally, under most models, an ACO does not exist without a panel of specialists. Layer on the often-strained relationships between hospital administrators and specialists, as well as those between primary care physicians (PCPs) and specialists, and the challenge gets even more acute. There is an expectation that in this “medical neighborhood,” specialists will be good neighbors.
Identifying the Greater Evil
Where is the need for coordination greatest? Although I specifically list 4 scenarios, I am sure there are many more:
1. Streamlining patient referral.
Referral for specialist care is a dysfunctional process. Bidirectional and accurate communication between the referring physician and the oncologist is key and works better than giving the patient a stack of papers with the kernels of truth buried deep. A methodology for electronic triage would be a really useful tool. Let’s give patients access to all electronic communication relevant to their case. Interestingly, many virtual second opinion programs do just this, following completion of a virtual case report form. Currently, it is a manual process, but it doesn’t have to be.
For patients that do require the consultant’s care, a navigator can be a priceless (and, ultimately, deeply loved and appreciated) patient partner on the care journey. And remember that in an integrated network, there will be a strong disincentive to referral as consultants consume resources. So good communication as to why consultation is not required will be just as important. The result: ACO savings, transparent evaluation, potentially better quality of care, and happier patients.
2. Managing the patient with complex comorbidities.
A second obvious area currently lacking coordination is the treatment of patients with complex comorbidities. These patients pose major challenges for the oncologist for several reasons:
- They take up a lot of the healthcare provider’s time
- They frequently suffer complications
- The oncologist is ill-suited to manage some of the medical problems
The current default—referral back to the PCP or another specialist—is highly inefficient, often inconvenient (and sometimes costly) for the patient, and invariably accompanied by poor communication of the clinical ask. This is certainly a cause of unnecessary hospitalizations, and it certainly makes patients deeply unhappy. The easy target is the darn doctor…if only they would just get on the phone. But that has always been the solution, and it hasn’t worked very well. The solution here is probably adoption of a care team mentality. There is little doubt that a skilled nurse practitioner can facilitate the hand-off of these complicated patients on both ends of the transaction. Again, an electronic solution would make things so much better.
3. Optimizing end-of-life care.
Advanced care planning discussions are very difficult and not particularly enjoyable for many. Evidence shows that many oncologists do not do a very good job with this,1 even though they steadfastly maintain that they “own” these discussions and become irate if someone else has the audacity to intervene. Now, with the evidence that palliative care providers significantly improve patient care at the end of life, there is need for facilitating their access to these patients (and, with that, the need to coordinate care).
Besides the obvious need for oncologists to “get over” their territorialism, effective integration of these providers into the care team will unquestionably improve the quality of care throughout the care continuum and likely reduce costs. There is no doubt that if oncologists do not solve this problem, the integrated delivery system will do it for them—and patients will like it (or so the data say).1 Do not forget that the PCPs also need to be kept in the loop. For many patients, these doctors manage families across generations and enjoy tremendous trust and respect. Again, an electronic solution appears needed.
4. Transitioning to survivorship.
Finally, it is not unfair to say that survivorship care is a mess. It is the epitome of a nonstandardized, nonevidence-based mélange, and this may be the single area most in need of improvement in coordination of care. Oncologic elitism has made it very difficult for most PCPs to re-assume the care of their cancer survivors, and this uneasiness is readily perceived by patients who interpret it as incompetence. If they only knew the truth!
Oncologists are expensive, and they do not do a very good job of primary care. Studies have shown that survivors expect their oncologists to assume responsibility for health maintenance (especially cancer screening), yet they rarely do (in fact, they do not consider themselves responsible).2 An appropriate care transition would probably be in everyone’s best interest, but it rarely happens. ACOs, however, will demand it. Interestingly, part of the Institute of Medicine’s (now the National Academy of Medicine) 13-point care plan, which is now required as part of the Center for Medicare & Medicaid Innovation’s Oncology Care Model, is a survivorship plan. Pity is, no one knows what to put there. In addition to the establishment of evidence-based standards, a methodology to document and communicate these recommendations to patients, and the rest of the care team, is needed.
Oncologists will not disagree with these gaps—we see the impact of these care gaps every day. What most oncologists do not realize is that healthcare reform will require solutions, and fast. One could argue that people are not “hurt” by these gaps, that there is no evidence they impact outcomes. Patients, however, sure do not like them, and if they negatively impact the financial outcomes of an integrated delivery system, they will not be tolerated. Healthcare reform is doing oncology a favor by forcing it to do the right thing.
Where Do We Start?
A good place would be interoperability. The Cancer Moonshot initiative identifies it as a priority (although not a major one); in my opinion, it would be fine if we spent every last Moonshot dollar on just this problem. For integrated delivery systems where all the doctors are employed, all working on the same dysfunctional electronic health record, perhaps this is not the issue. But in oncology, despite the migration of oncology practices to hospital ownership, more than half of the care is still being delivered by independent community oncologists. So, these bridges need to be built.
The next step is to adopt a team approach to care management. This doesn’t mean assigning people new jobs. It means convincing every clinician, every clerical staff member, every person that touches a patient, that they are vital to the best patient experience. And if they are vital, they should be treated with respect. Aspirational? Perhaps. But we are all patients-in-waiting, and it is only fair to ask what we would expect if the care were being delivered to us. We have healthcare reform to thank for moving us in the right direction.
1. Kumar P, Temel JS. End-of-life care discussions in patients with advanced cancer. J Clin Oncol. 2013;31(27):3315-3319. doi: 10.1200/JCO.2013.49.6562.
2. Cheung WY, Neville BA, Cameron DB, Cook EF, Earle CC. Comparisons of patient and physician expectations for cancer survivorship care. J Clin Oncol. 2009;27(15):2489-2495. doi: 10.1200/JCO.2008.20.3232.