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Streamlining Cancer Care: Affordability and Accountability

As policymakers, patients and healthcare clinicians begin tofind their way through the maze of changes outlined and endorsed under theAffordable Care Act, some providers are calling for further restructuring toaddress what they call missed opportunities in the legislation. While theguidelines aim to improve the quality of care delivered to patients andsimultaneously reduce cost growth, it seems to the focus is largely on patientswith certain illnesses, such as heart disease. Though the benefit to thosepatients is no small feat, health care reform directed at the large and costlycancer patient population is being overlooked according to a newcommentary published this week by JAMA Internal Medicineand authored by faculty at the PerelmanSchool 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 thecourse of treatment and follow-up care – requires a multidisciplinary andmultispeciality team of health care providers. Cancer patients work with a teamof experts including their primary care physicians (PCPs), surgical teams,radiation oncologists, and so on…

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

Together with co-authors from Penn Medicine, JustinBekelman, MD, assistant professor of Radiation Oncology at Penn Medicine, saysthat under current payment structures, cancer specialists are economicallyincentivized to “deliver more care, be it surgeries, chemotherapies, orradiation 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 intesting and treatment and further improve the quality of care delivered tocancer patients, Bekelman suggests the formation of Cancer Care Groups (CCGs)to formalize the group of health care providers and foster a more collaborativeapproach 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 wouldcoordinate with PCPs and palliative care specialists.

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

“By paying for oncology services with a lump sum tied toquality of care metric, we would see equivalent or higher quality care atreduced cost,” says Bekelman. “Instead of incentivizing cancer specialists todeliver more care through excessive treatments and procedures, they would beincentivized to use evidenced based care that meets the bar of nationalclinical care guidelines.”

Bekelman and his colleagues acknowledge that more worksneeds to be done on the back-end to establish a proper regulatory and legalstructure for this model to excel. Still, with an end result that deliverssuperior care to the patient, and reducing the overall cost of treatment, theyargue that the platform deserves consideration.

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

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

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