Community Oncology Is Key in Ensuring Access to Cancer Care

December 2017, Vol 8, No 5

This special feature is supported by funding from Janssen Pharmaceutical Companies of Johnson & Johnson.

Community oncology has an important role in eliminating barriers to accessing healthcare and reducing disparities in cancer care. Improving access to high-quality, cost-effective cancer care was addressed from a variety of perspectives at the 2017 Association for Value-Based Cancer Care Summit.

Rose Gerber, Director, Patient Advocacy and Education, Community Oncology Alliance (COA), Washington, DC, discussed the challenges in access to care from the patient perspective, specifically the consolidation of cancer clinics. COA is a national nonprofit organization dedicated to preserving access to cancer care at the community level.

Lack of proximity to healthcare services is one consequence of cancer clinic consolidation, a trend that has been accelerating in the past few years. The 2016 Community Oncology Practice Impact Report cited the closing of 380 clinics, with another 390 oncology practices struggling financially.

“Most cancer patients are very well-versed on their disease, finding out what they need to find out, what kind of drug they should be on,” said Ms Gerber. “But something that patients don’t think about, and this is my job with COA, is to teach the cancer patients to get educated about understanding that cancer centers are in fact a business,” she added.

The concern that patients have about cancer clinic consolidation is the lack of continuity of care and the end to a personal relationship. “One of the things that make cancer manageable is knowing that you have a physician who doesn’t treat you like a number,” said Ms Gerber.

Benefits of the Clinic Pharmacy

Ricky Newton, CPA, Director, Financial Services and Operations, COA, Virginia Beach, VA, addressed access to care challenges from the pharmacy perspective, noting the explosion of oral oncolytic drugs and the involvement of pharmacy benefits managers (PBMs).

Over the years, community oncology practices have opened facilities within their practices to provide pharmacy services to save patients from relying on specialty pharmacies and other retail pharmacies. The emergence of the PBM has led to the clinic pharmacy being removed from dispensing oncolytic drugs, because patients are often required to have their oral cancer drugs filled at a specialty pharmacy that may be owned by the PBM. The patient assumes that the switch to the specialty pharmacy was directed by his or her physician or pharmacist, who often has no knowledge of the directive.

“The best patient care comes at that place of the point of care, whether it’s in an academic center, a hospital, or at the physician practice,” said Mr Newton. “Wherever that patient is being treated, the best care is right at that point, because you’ve got all the nurses, the midlevel providers, medical assistants. Everyone is right there taking care of the patient. As soon as you pull them out and give them to a middleman with nurses that aren’t seeing the patients face to face, things happen,” he added.

Caring for patients on a 24/7 basis has tangible benefits in the form of fewer treatment delays, keeping patients out of the hospital, promoting adherence to therapy, and suggesting hospice when appropriate, thereby lowering costs. Furthermore, the patient’s care team is best suited to recognizing early signs of response and adverse reactions that may necessitate a drug switch, resulting in less waste.

“One of the areas that we have been very successful on in community oncology as a whole is being able to provide patient assistance, especially in the oral arena to all patients in need,” said Mr Newton. Funding for patient assistance programs is drying up, with less contribution from some pharmaceutical companies, he added.

Patient Cost Burden on the Rise

Dawn G. Holcombe, MBA, FACMPE, ACHE, President, DGH Consulting, South Windsor, CT, addressed the increasing patient cost burden and its effect on access to care, calling the expectation of access to high-quality care for all Americans unrealistic. The “skin in the game” requirements are rising, and every time they do, “somebody is going to not choose to get healthcare,” she said. In-network versus out-of-network changes have the same result.

Treating patients from a population management perspective will lead to better care and cost control, but not until siloes of care are removed. For this to happen, the focus must shift from outside the 4 walls of the clinic to engaging and tracking the patient outside the office. Although a physician and a payer may agree on the most appropriate treatment for a patient with lung cancer, and the patient receives that treatment in the clinic, “if no one is paying attention to what that patient is going home to, they may go home to a non–air conditioned apartment in Texas in the middle of summer,” said Ms Holcombe. “Suddenly, they find themselves in the emergency department with breathing problems,” which leads to higher costs.

Thinking about the entire patient includes consideration of comorbidities, and an assurance that the patient will receive appropriate management for those comorbidities. “That communication may be easier if all the physicians are part of a larger network and a larger system,” said Ms Holcombe.

Partnerships Build Resources

Building partnerships brings resources for value-based cancer care, said Linda D. Bosserman, MD, FASCO, FACP, Medical Advisor, City of Hope Medical Group, Rancho Cucamonga, CA. Partnerships between large care-delivery networks (eg, community, hospitals, academic, health systems) enable the collection of robust data that are necessary to evaluate clinical and financial outcomes.

“We really need to have discrete data entry at the point of service. I think that’s the biggest change we need to push for,” said Dr Bosserman. Such entries for a patient with cancer would include genetic mutations at the time of presentation, time of first and second disease recurrence after treatment, and resistance mutations that may determine subsequent treatment.

Consolidation will engender a more integrated care process that should expand access to high-quality care through hub and satellite models, telemedicine, 24/7 triage, clinical pathways, and even phone applications, contended Dr Bosserman.

The adoption of an electronic medical record (EMR), such as Epic, will enable access to key patient and treatment data that will allow clinicians and administrators to better understand the impact of treatment decisions and their associated costs.

“Even our poor patients all have phones,” Dr Bosserman said. “Phone apps are going to be the main way that people are communicating. You can prompt for side effects, prompt for medication compliance, identify early on side effects, and contact that patient and help avoid hospital and emergency room visits,” added Dr Bosserman.

Clinical Pathways and Technology

Point-of-service clinical pathways will expand and change rapidly as treatments evolve, ensuring the standardization of care and proper supportive care. Clinical pathways from Via Oncology and the National Comprehensive Cancer Network will be implemented into Epic within the next 18 months, she predicted. “The iKnowMed EMR already has a [clinical] pathway system fully embedded,” said Dr Bosserman.

The adoption of technology is also paramount to supporting clinicians. “We’ve got to have our systems set up to let doctors think, give them the data, and let them build teams that can help care for patients, and do it on a 24/7 basis,” she said.

“If we’re going to retain good talent, we have to make it a profession where we can still think, and bring research, and take care of patients in a way that improves access,” Dr Bosserman concluded.

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