Education Session Highlights Novel Approaches to Improve Cancer Care, Rein in Costs

The cost of medical care continues to spiral upward, to the growing concern of patients, physicians, employers, and insurers. Proper management of resources not only reduces costs but more importantly results in better, more efficient patient care.

Quantifying the cost of medical care is increasingly crucial in order to demonstrate to patients, employers, and insurers that the best medical care is being delivered in the most cost-effective manner. These were the key messages that presenters delivered to the audience at the Education Session "Doing It Right, and for Less: Implementing Practice Changes to Manage the Growing Complexities, Inefficiencies, and Costs of Cancer Care."

Session Chair Adam Brufsky, MD, PhD, of the University of Pittsburgh Cancer Institute at the University of Pittsburgh School of Medicine (UPMC), described “oncology pathways” that he and his colleagues have developed and which encompass 25 sites and extend over a 250-mile area.

The oncology pathways were developed due to concern over the quality and consistency of care delivered by this large oncology consortium. Dr. Brufsky said that these guidelines are not like those of the National Comprehensive Cancer Network, which may include many treatment options for specific types of cancer; rather, the goal is to establish a single therapeutic option intended to provide optimal therapy for approximately 70% to 90% of the patient scenarios that might be encountered. Oncologists are not bound to follow the pathways but must offer explanations for treating off-pathway.

Treatment of patients who fall outside this rubric is discretionary, but the information is captured and given consideration in the cyclical process of updating the pathways.

The pathways take from 6 to 12 months to develop. They are evidence-based treatment algorithms, which are developed by committees composed of the oncologists themselves. The pathways are consensus-driven, with decisions emailed to the entire physician group for comments prior to finalization, giving everyone a sense of ownership in the process.

The individual disease committees define a single best option, based on the following considerations: first tier: efficacy; second tier: safety profile, if treatments are of comparable efficacy; and third tier: cost, if and only if, efficacy and toxicity are comparable.

The pathways are delivered in a point-of- care, patient-specific, computer-based interactive decision-support tool, which can be incorporated into the medical health record, whether it’s electronic or paper-based. The decision tool can interface with the practice’s demographic and scheduling applications and also be used as a mechanism for clinical trial accrual: the first therapeutic option is always any practice-specific clinical trials that are ongoing.

The captured data and its subsequent analysis can provide measurable proof of performance. Dr. Brufsky said that for the year ending December 31, 2011, 82% of patients at UPMC were treated "on pathway." Dr. Brufsky also provided two examples of analyses of total cost of care conducted by UPMC and Healthmark, a large insurer, comparing costs before and after initiation of the clinical pathways program. The total cost of care for breast cancer treatment over 12 months was reduced by 9% (absolute growth rate deduction); for non–small cell lung cancer the absolute growth rate was reduced by 5%.

Simple Tools Can Clarify Patient Expectations and Concerns

Bruce E. Hillner, MD, of Virginia Commonwealth University, described how a checklist can be used to integrate palliative care into typical oncology care in a standardized manner. This two-page document has not yet been systematically assessed, but Dr. Hillner believes that it has helped reduce stress for patients reaching end-of-life decisions, as well as for oncologists who often are concerned that patients will equate stopping chemotherapy with abandonment.

The checklist, which the oncologist fills out with the patient, includes a section describing the treatment chosen and the estimation of individual performance status. In other sections, the patient checks off whether he or she wants specific information about prognosis, goals of therapy, and possible side effects. If the patient wishes to know more, the checklist helps the oncologist initiate what may be difficult conversations (Figure).

Another section of the checklist addresses issues that may be discussed with patients by another member of the staff, including staff who can help with legal issues such as advance directives, durable power of attorney, and wills. It also addresses what Dr. Hillner referred to as "the soft hard stuff," including questions such as, Who can help me talk with my children/spouse? Who is available to help me cope with spiritual and psychological issues? What do I want to pass on to my family to tell them about my life? In closing his presentation, Dr. Hillner said that simple, standardized instruments can go a long way in changing attitudes toward oncologists and their methods.

Better, Faster, and More Affordable Care

Henry O. Otero, MD, of Virginia Mason Medical Center (VMMC), described how he and his colleagues have applied the Toyota Production System (often referred to as the "lean" or "just-in-time" principle) to the VMMC strategic plan for improving the health and well-being of the patients they serve.

The initial premise, said Dr. Otero, was that high-quality care starts with identifying and removing waste, the basic tenet of the Toyota Production System.

VMMC cooperated with local employers and health plans to define their concepts of high-quality care. As a result, VMMC is providing the following:

• "Just the care that works"—Achieved by incorporating evidence-based medicine to reduce needless testing and nonstandard therapies and provide optimal patient care
• "Just the right provider"—Achieved by assessing labor costs and skill/task alignment to allocate personnel to appropriate functions
• "Just in time"—Achieved by value stream-mapping to reduce the waste of time, by redesign of the physical workplace to reduce waste of motion, and by standardization of work processes

As an example, Dr. Otero noted that patients now have same-day access at the breast clinic for evaluation by an advanced registered nurse practitioner, screening tests, and a biopsy if necessary, with results provided to the patient within 72 hours. The same level of service previously required several patient visits over more than 3 weeks, which raised employers’ costs, due not only to absenteeism, but also to "presentee-ism," or the costs associated with employees’ preoccupation with their medical condition during the interval between making an appointment and receiving biopsy results.

In closing, Dr. Otero stated that VMMC is using lean system principles to remove waste and deliver better, faster, and more affordable health care.