'Fragmented' cancer care

The cancer-care system in the U.S. is fraught with waste, skewed financial incentives and misinformation about how to provide the best care to the 1.6 million people who are diagnosed with cancer each year.

In a critical report, the Institute of Medicine said the nation's “increasingly chaotic and costly” cancer-care system is in crisis and fails to deliver consistent care that is patient-centered, evidence-based and coordinated.

The report identified issues across the oncology spectrum of care, finding that community oncologists don't always follow or stay up to date with clinical treatment guidelines, genomic advances have made treatment more complex and more expensive, and there has not been enough of an effort to engage patients and provide palliative care.

“Cancer care has just become a lot more complicated and fragmented and more challenging to deliver,” said Dr. Patricia Ganz, director of cancer prevention and control research at UCLA's Jonsson Comprehensive Cancer Center and chair of the IOM committee that wrote the 315-page report. This is the first major IOM look at cancer care since 1999, and she said some gaps found in that 1999 report still exist.

But some health systems around the country have already begun to address the issues highlighted in the report, and payers such as Aetna and UnitedHealth have launched programs to provide more cost-effective cancer care. “The bottom line is that providers aren't sitting still,” said Matthew Farber, director of provider economics and public policy for the Association of Community Cancer Centers.

For instance, Pennsylvania-based Geisinger Health System assigns nurse navigators to assist patients with care coordination and help with communication among physicians. In addition, the system reviews national guidelines to ensure state-of-the-art treatment, and patients and their primary-care physicians are given treatment summaries that detail all procedures performed, as well as follow-up care plans.

The New York City Health and Hospitals Corp. has formed a comprehensive cancer center in several of its largest facilities, enabling its providers to deliver care in a multidisciplinary way. Aetna partnered with the US Oncology Network for a shared-savings program that requires physicians to use a software system that provides clinical decision support and also requires documentation of the use of clinical guidelines for patients with lung, breast and colon cancers. Last year, the insurer reported the program reduced costs by 12%, including a 40% drop in emergency room visits and a 17% decrease in hospital admissions.

The IOM report said new payment models that remove prescribing incentives for physicians, along with the introduction of information technology tools to collect patient data, offer promising methods to help improve care and reduce costs. But they are not widely used by healthcare providers, and the current reimbursement system does little to incentivize the kind of care that could improve quality.

“There's a lot of waste in tests and procedures that are being done because of poor coordination of care and duplication,” Ganz said. “If that were eliminated, a lot of the waste would be eliminated. There would be plenty of money to … give reimbursement for the time spent with patients explaining their treatment, their prognosis and developing a care plan.”

The report makes 10 recommendations, which generally focus on the need to provide better information to patients, ensure coordinated and patient-centered care, incorporate the use of data, reduce disparities in access and improve the affordability of cancer care.

Experts say they agree with the IOM's assessment that the U.S. cancer-care system is in crisis. They cite challenges including the rising costs of targeted therapies, the current reimbursement models for oncology practices and delays in widespread adoption of data and IT tools.

“A lot of the issues that they appropriately highlight are structural but not insurmountable,” said Dr. Clifford Hudis, president of the American Society of Clinical Oncology. When asked if ASCO had concerns about the report's findings, he said that the “the core issue that they identified is the need to maintain and enhance quality, and we just couldn't agree more.”

More patients who are part of a rapidly aging population are getting diagnosed with cancer. The number of new cancer cases diagnosed each year is expected to rise to 2.3 million in 2030 from about 1.6 million now. The cost of cancer care is rising two to three times faster than other healthcare costs, driven in part by advances in genomic science that have led to the development of expensive targeted therapies as well as by the overuse of certain tests and imaging. Those costs are expected to rise 39% to $173 billion in 2020 from $125 billion in 2010.

The report said “oncology care is an extreme example of the best and worst in the healthcare system today—highly innovative targeted diagnostics and therapeutics alongside escalating costs that do not consistently relate to the value of treatments, tremendous waste and inefficiencies due to poor coordination of care, and lack of adherence to evidence-based guidelines with frequent use of ineffective or inappropriate treatments.”

Cancer care is complex for many reasons. There are hundreds of types of cancers, and strides in genomic science during the past decade or so have further broken down the various types of cancers and how they should be treated. It can require surgery, radiation or chemotherapy, or a combination.

And providers are starting to learn more about host factors that can indicate why the same cancer affects two people differently and the different ways that patients metabolize drugs. Some patients also have other comorbidities, which can increase the complexity of their case and make it more difficult to fit their care into certain guidelines.

For less complex cases, oncologists say it's still a struggle to keep up with rapidly evolving clinical guidelines for cancer care.

“It's really challenging for the average medical oncologist who may see melanoma, breast cancer, thyroid cancer (and) colon cancer to know at the tip of their fingertips every disease and its permutations and what's the best treatment,” Ganz said.

As a result, patients sometimes receive inappropriate treatments and are uninformed about their prognosis, the costs of treatment and in what ways treatment will impact them. In other instances, patients with metastatic cancer may advocate for ongoing treatment that is unnecessary.

The IOM report also highlighted the problem of perverse financial incentives for physicians.

“Doctors are actually not necessarily reimbursed to talk to each other and plan a patient's care,” said Dr. Otis Brawley, chief medical officer for the American Cancer Society. “That in itself is a huge, huge handicap.”

Another example relates to how physicians are reimbursed for the drugs they prescribe.

Dr. Ira Klein, Aetna's national medical director for clinical thought leadership, said “it's the only disease category where the medical specialists treating the patient have as their primary business model making money from the drugs they prescribe.”

The IOM and oncologists say providing patients with more information and education helps them understand treatment options.

New care and payment models formed by providers and insurers are expected to align quality and cost through coordination, with some now starting to increase their focus on the patients.

“The support for cognitive services is relatively modern,” ASCO's Hudis said. “Historically, there's not been a tremendous amount of support financially for the time and effort and thinking that goes into making a plan and coordinating the care with many other doctors.”

This may be changing. There have been in recent years a number of successful programs, many of which have been driven by health insurers that are seeking ways to better tie payment to improved quality and lower costs.

“Unless we're really patient-centric, we can never really get to where we want to be with value in cancer care,” Klein said.

At Geisinger, cancer treatment and treatment planning is initiated in multidisciplinary clinics where new patients on their initial visit see a number of specialists who conduct multiple evaluations and then come together to devise a coordinated plan of care. “The multidisciplinary clinics are very integral to what we do in our initial cancer treatment planning,” said Dr. Victor Vogel, director of breast medical oncology and research at Geisinger.

To further coordinate efforts, patients and their primary-care physicians are given treatment summaries that detail all procedures performed, as well as a plan for their follow-up care. “The burden of cancer care is going to be so great this will require that primary-care physicians participate in the long-term follow-up of patients,” Vogel said.

The New York City Health and Hospitals Corp.'s cancer center serves a large low-income population, so it has conducted an extensive outreach program that has included breast and prostate cancer screenings, said Dr. Margaret Kemeny, director of the Queens Cancer Center at Queens Hospital Center. The result has been a decline in the rate of late-stage breast cancer among center patients, down from 33% in 2002 to 16% last year at the Queens facility.

“In one area, all of our cancer practitioners are housed,” Kemeny said. “That allows us to do a lot of multidisciplinary care, which is what's really going to be needed in the future.”

Better use of data and technology is expected to be a key driver in improving the cancer-care system. The IOM noted that data tools such as electronic health records and cancer registries are in place. However, those tools are “incompletely implemented, have functional deficiencies and are not integrated in a way that creates a true learning healthcare system.”

ASCO plans next year to launch a health IT-based system called CancerLinQ, which will collect and analyze cancer-care data and generate real-time personalized clinical decision support and feedback.

“As the complexity of cancer increases, as the molecular biology becomes more and more specialized, it's become harder for any human to keep up with all of the sudden and nuanced developments in the various areas,” Hudis said. “It is clear that docs want to do the right thing, and what we have to do is make it easier for them.”

Follow Jaimy Lee on Twitter: @MHjlee

Follow Steven Ross Johnson on Twitter: @MHSjohnson