New Collaborative Advance Care Planning Program for Patients with Cancer Enhances Quality while Mitigating Costs

September 2013, Vol 4, No 7

The cancer care landscape is rapidly evolving, in light of promising new therapies, as well as changing reimbursement strategies in response to the healthcare reform. With the cost of some cancer drugs exceeding $100,000 annually, and with patients living longer, cancer care consumes a large portion of healthcare dollars. Medical expenditures for cancer are projected to reach at least $158 billion in 2020, an increase of 27% over 2010, according to the National Cancer Institute.1 There is little debate that these costs are unsustainable, and that cancer care must migrate to a more value-based treatment model.

The US Oncology Network, with the support of McKesson Specialty Health—one of the largest US cancer care networks, representing nearly 1000 physicians—recognizes the need for value-based reform and is at the forefront of developing innovative strategies that optimize value while supporting quality care and improving outcomes.

One area that presents a potential for improved cost control and, more important, for an improved patient and family experience, is end-of-life care. A recent study by the Dartmouth Institute concluded that approximately 25% of all Medicare spending is for patients in their last year of life.2 Providers who treat patients with advanced-stage cancer know that aggressive care at the end of life is often ineffective and costly. High-intensity, last-attempt efforts can have a negative effect on the quality of life of patients, as well as on the lives of caregivers. Patients at this stage need a thorough understanding of the risks and benefits of the treatment that they are requesting or getting.

As providers for terminally ill patients, and as stakeholders in a healthcare field with limited resources, we must ask if there is a better way to manage late-stage disease, so that patients have the opportunity to determine their own care preferences and to better comprehend the pros and cons of various treatment options. Helping patients understand and specify the care they want can minimize unwanted and ineffective treatment, provide a better end-of-life experience, and help reduce the cost burden on our patients and on society.

My Choices, My Wishes Program
The US Oncology Network, in collaboration with McKesson Specialty Health, has tackled this problem by developing a patient-centered advance care planning program to mitigate costs, improve quality care, and provide a better patient experience. The program, “My Choices, My Wishes,” provides an avenue for quality, cost-effective care by helping patients explore, define, and document the care they desire throughout their cancer journey. Providers seek to discover a patient’s values and goals for care across their disease trajectory, including end-of-life care. Discussions begin early, at a time when medical decision-making can still be thoughtful.

The program is typically introduced to patients by their physician early on and includes specially trained mid-level providers and social workers, and educational and resource materials. Healthcare information technology is used to identify patients, store treatment progress and preferences, define and document directives, and honor patients’ wishes throughout their care plan.

My Choices, My Wishes uses an ongoing, systematic process that gives patients the opportunity to continually revise their healthcare goals and reevaluate the care and experience they desire during their cancer treatment. The goal is to simplify a complex situation by helping patients understand and continually define what is important to them as disease progression occurs, giving them a voice in advanced-stage treatment decisions and helping them to live well during their illness.

The program is unique in providing benefits to all stakeholders?patients, families, physicians, and payers. It helps patients to achieve the quality of life they desire by explaining their care options and placing these options into their values perspective. Advance care planning empowers patients to make decisions before a medical crisis occurs, while they still have time to carefully think about what gives their life meaning and purpose.

Reduced Utilization at End of Life
Patients with terminal cancer who participate in similar programs typically stop chemotherapy at a reasonable point and transition to a comfort care plan, allowing them to experience the benefits of palliative and hospice care. Because the patient has clearly documented and made known the treatments he or she wants over time, the program can reduce the patient’s stress level and can also provide a better experience for loved ones, who are relieved of the bur­den of decision-making in emotional circumstances.

My Choices, My Wishes also delivers significant benefits to cancer practices and can strengthen referring physician relationships. Practices can use the program’s provider documentation tools and outcome metrics to increase appropriate hospice referrals and to help ensure appropriate chemotherapy utilization patterns. In addition, the program provides potential for multiple revenue streams from innovative, value-based savings payment models and increased evaluation and management coding.

Potential for Reduced Costs
Payers can also benefit by participating in the program. By approving evaluation and management charges for mid-level providers and/or social workers to discuss and document healthcare goals with patients, payers can support more cost-effective care. A recent study in the Journal of Clinical Oncology showed a clear connection between early discussions with patients about end-of-life preferences and savings on unwanted or ineffective care.3

My Choices, My Wishes supports the documentation of advance directives and do not resuscitate orders, while promoting increased hospice referrals and hospice length of stay—all of which play a vital role in the enhancement of a patient’s quality of life and a reduction of high-intensity treatments and their associated costs.

Payers also have the opportunity to collaborate with providers to review outcomes from the program, including analyzing claims data in ways that assess acute care savings, decreased chemotherapy in the last month of life, and hospice utilization.

The ability to create opportunities to reduce overall healthcare costs while enhancing high-quality care and the patient experience makes the program attractive to payers, and several national insurance companies are collaborating with practices within the US Oncology Network to provide their members access to the program.

My Choices, My Wishes is a promising step toward transforming can­cer care into a more value-based system, without sacrificing quality and
outcomes.

References

  1. Mariotto AB, Yabroff KR, Shao Y, et al. Projections of the cost of cancer care in the United States: 2010-2020. J Natl Cancer Inst. 2011;103:117-128.
  2. Goodman DC, Esty AR, Fisher ES, Chang CH. Trends and variation in end-of-life care for Medicare beneficiaries with severe chronic illness: a report of the Dartmouth Atlas Project. April 12, 2011. www.dartmouthatlas.org/downloads/reports/EOL_Trend_Report_0411.pdf. Accessed July 2, 2013.
  3. Mack JW, Cronin A, Keating NL, et al. Associations between end-of-life discussion characteristics and care received near death: a prospective cohort study. J Clin Oncol. 2012;30:4387-4395.

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