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Streamlining Cancer Care: Affordability and Accountability

As policymakers, patients and healthcare clinicians begin to find their way through the maze of changes outlined and endorsed under the Affordable Care Act, some providers are calling for further restructuring to address what they call missed opportunities in the legislation. While the guidelines aim to improve the quality of care delivered to patients and simultaneously reduce cost growth, it seems to the focus is largely on patients with certain illnesses, such as heart disease. Though the benefit to those patients is no small feat, health care reform directed at the large and costly cancer patient population is being overlooked according to a new commentary published this week by JAMA Internal Medicine and authored by faculty at the Perelman School of Medicine at the University of Pennsylvania.

As any cancer patient can attest, the delivery of care – from the diagnosis, to the formulation of a treatment plan, and throughout the course of treatment and follow-up care – requires a multidisciplinary and multispeciality team of health care providers. Cancer patients work with a team of experts including their primary care physicians (PCPs), surgical teams, radiation oncologists, and so on…

While these multidisciplinary teams bring together a wealth of knowledge to deliver the best care possible to the patient in the hope of a positive outcome, knowledge and expertise doesn’t come cheap and these teams can often end up generating high costs and care variability. What’s more, according to the authors, the organizational structure of these teams “does not fit neatly into current concepts of accountable care organizations.”

Together with co-authors from Penn Medicine, Justin Bekelman, MD, assistant professor of Radiation Oncology at Penn Medicine, says that under current payment structures, cancer specialists are economically incentivized to “deliver more care, be it surgeries, chemotherapies, or radiation fractions, rather than evidence-based care.” At the end of the day, this uncoordinated care results in overuse of unnecessary tests and treatments, avoidable hospitalizations, and gaps in the management of comorbid illness.

In an effort to curb spending, reduce redundancies in testing and treatment and further improve the quality of care delivered to cancer patients, Bekelman suggests the formation of Cancer Care Groups (CCGs) to formalize the group of health care providers and foster a more collaborative approach to delivering care. Under this structure, panels of surgical, radiation and medical oncologists would provide comprehensive cancer care “throughout the arc of patients’ progressive cancer care needs” and would coordinate with PCPs and palliative care specialists.

This effort to align health care processes would also result in an altered payment structure, whereby CCGs would be compensated under a bundles system, receiving “a single payment for each patient according to the diagnosis and stage of disease, risk adjusted for factors like disease severity and comorbid illnesses and adjusted for local cost of living.”

“By paying for oncology services with a lump sum tied to quality of care metric, we would see equivalent or higher quality care at reduced cost,” says Bekelman. “Instead of incentivizing cancer specialists to deliver more care through excessive treatments and procedures, they would be incentivized to use evidenced based care that meets the bar of national clinical care guidelines.”

Bekelman and his colleagues acknowledge that more works needs to be done on the back-end to establish a proper regulatory and legal structure for this model to excel. Still, with an end result that delivers superior care to the patient, and reducing the overall cost of treatment, they argue that the platform deserves consideration.

“Rather than cutting physician payments across the board, CCGs reward cancer specialists and PCPs for delivering high-quality cancer care and reducing cost growth,” the article states, adding that the CCG represents “a new structural and payment-reform vehicle that has the potential to drive toward accountable cancer care.”

For a closer look at the proposed CCG structure, see the full commentary on JAMA Internal Medicine here.

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