This article was written in response to the Viewpoint: "Rethinking Health Care Delivery."
As patients’ financial responsibility for their care increases, the burden of this patient responsibility is becoming a barrier to treatment. We must rethink the way in which health care is delivered, with an improved focus on care coordination, patient engagement in care, and population- or condition-specific treatments through clinical pathways.
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The health care delivery system is a complex labyrinth of concurrent processes, focused on providing health care services to an individual patient. However, as Mr Woody points out, while these concurrent processes are operating towards a specific goal, have we lost the humanistic element that makes the result one that is valued by the patient? This is not to say a positive clinical outcome is not valued by the patient; however, at what price was that clinical outcome achieved by, and is that price acceptable by the patient?
The question of whether the patient was engaged into the treatment decision process is a valid one, and one that is being asked more and more today. As the cost of health care increases, driven by new technologies and medications, are we seeing any return? As Peter Bach stated at the National Comprehensive Cancer Network (NCCN) 20th Annual Conference: “…[W]hile the cost of introductory cancer drugs is increasing rapidly, there has not been a commensurate increase in benefit.” This statement was based on a study assessing trends in the launch prices for 58 anticancer drugs approved between 1995 and 2013 in the United States.1 A consequence of the rising cost of health care is an increase in patients’ financial responsibility for their care, in the form of either a copayment or co-insurance. The burden of this patient responsibility is becoming a barrier to treatment. With an average coinsurance of 20% to 30%,2 the patient responsibility can easily reach nearly $40,000 annually, on top of the premium cost, if incurred directly by the patient. It is estimated that cancer patients are 2.5 times more likely to file for bankruptcy than patients without a cancer diagnosis.3 Such concerns were one of the drivers for the American Society of Clinical Oncology to develop the its Value Framework4 and NCCN to develop its Evidence Blocks,5 both of which are tools that can be used to initiate discussions with patients regarding the cost and effectiveness of various treatment options.
In concept, the engagement of the patient, as Mr. Woody suggests, is not a new one. As far back as 2007, the concept of the “Triple Aim” was coined by Don Berwick at the Institute of Healthcare Improvement, representing the goals of: (1) improving the individual experience of care; (2) improving the health of populations; and (3) reducing the per capita costs of care for populations.6 Berwick describes that success in achieving the Triple Aim requires that the population served become continually better informed about both the determinants of their own health status and the benefits and limitations of various treatment options. The hope would be that allowing the patient to be better informed would help to change the “more is better” culture through transparency, systematic education, communication, and shared decision making, rather than by restricting access, shifting costs, or creating administrative hurdles to care.
One of the first alternative care models to embrace the Triple Aim is the patient-centered medical home (PCMH), created through a collaboration effort of the American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, and American Osteopathic Association.7 The PCMH model is built upon five pillar principles, one of which is “patient-centered orientation,” where care is tailored toward each patient’s unique needs, culture, values, and preferences; patient efforts in self-care are engaged and supported; and the patient is involved in care plan decisions. The goal is to engage the patient and support the family to understand the possible outcomes of different treatment options, and then, in collaboration with the physician, discuss what is important in terms of the risks and benefits of those options. The end goal is an informed and collaborative treatment decision plan.
The Centers for Medicare and Medicaid Services (CMS) fortified patient-centered care in the Accountable Care Organization (ACO) framework.8 The clear goal of the ACO concept is to achieve a better overall health status through higher-quality care and lower costs with a focus on patients. The significant point here is that the organization is now being held “accountable” to achieve these goals. Key to an organization’s success is care coordination, patient engagement in care, and population- or condition-specific treatments. While not specifically defined as a clinical pathway, the reference to the development and integration of population- or condition-specific treatments is noted as a means of improving the quality and consistency of care provided. In the truest sense of a clinical pathway being comprehensive, the ACO toolkit, developed by the ACO Learning Network, suggests that a multifaceted approach that integrates different silos of care, including inpatient services, outpatient services, and patient self-management, have the greatest chance of reducing spending while improving quality. Thus, while the PCMH model supports the efforts of primary care physicians to coordinate care, the ACO model holds providers accountable for total per-capita costs.
The Oncology Patient-Centered Medical Home™ (OPCMH) model developed by Consultants in Medical Oncology and Hematology, PC (CMOH) was created based upon the key features of the patient-centered medical home in the primary care setting: open access, enhanced care coordination, comprehensive care, and sustained personal relationships.9 This model became the first oncology practice in the nation to achieve Level III recognition from the National Committee for Quality Assurance (NCQA). Essential to achieving Level III NCQA recognition was increased patient-physician communication, as well as increased communication with other treating physicians; test tracking and patient compliance monitoring; and care management and adherence to nationally accepted, evidence-based standards of treatment. To achieve these performance requirements, CMOH implemented the use of patient navigators to coordinate all aspects of cancer-related evaluation and services, as well as an interdisciplinary approach to management, based upon the NCCN guidelines. In short, the OPCMH embraced the concept of patient communications and engagement, as well as clinical pathways.
A total of 196 oncology practices have been selected to participate in the 5-year Center for Medicare & Medicaid Innovation Oncology Care Model (OCM).10 It is the intent of the OCM to aligned financial incentives, including performance-based payments, to improve care coordination, appropriateness of care, and access for beneficiaries undergoing chemotherapy. The model is intended to improve health outcomes, produce higher quality care, and lower costs. Practices must provide the core functions of a patient navigation program, as well as to treat patients with therapies consistent with nationally recognized clinical guidelines. Thus, patient communication and engagement, as well as treatment consistent with nationally accepted guidelines, are key to the program. While OCM does not dictate the specific requirement for the use of clinical pathways, due to the benefit of clinical pathways documented in the literature, it is almost a given fact that the use of clinical pathways will be needed in order to achieve performance and financial targets.
Thus, as we consider the concept of “ceasing to deliver health care,” it soon becomes evident that we do need to stop delivering health care as we know it today. There should be no disagreement that the health care system of today is fragmented, with little coordination and a nonalignment of incentives to strive for optimal outcomes, appropriate care, and controlling cost. Today’s health care delivery rarely includes patient considerations and value, bowing to what independent and disparate policymakers think the most appropriate plan of action should be. We can start with a population-based treatment recommendations; however, only through patient engagement and communications can the greatest value and outcome be achieved for an individual patient. The myriad of alternative care models being piloted today—eg, ACO, OCM, PCMH, and OPCMH—not only embrace the big picture of care coordination but also embrace the need for patient engagement and communication. The process by which we evaluate treatment and care options must be a collaborative process that includes the patient. Thus, there is hope that by focusing on the patient, as care options are evaluated and decided upon, we will achieve our goal of improving the general health of the population, improving the patient experience, and reducing cost.
References
1. Howard DH, Bach PB, Berndt ER, Conti RM. Pricing in the market for anticancer drugs. J Econ Perspect. 2015;29(1):139-162.
2. The Kaiser Family Foundation, Health Research & Education Trust. Employer Health Benefits 2014 Annual Survey. Henry J Kaiser Family Foundation; Menlo Park, CA; 2014.
3. Ramsey S, Blough D, Kirchoff A, et al. Washington State cancer patients found to be at greater risk for bankruptcy than people without a cancer diagnosis. Health Aff (Milwood). 2013;32(6)1143-1152.
4. Schnipper LE, Davidson NE, Wollins DS, et al. Updating the American Society of Clinical Oncology Value Framework: revisions and reflections in response to comments received. J Clin Oncol. 2016;34(24):2925-2934.
5. NCCN Evidence Blocks. https://www.nccn.org/evidenceblocks/. Accessed November 18, 2016.
6. Berwick DM, Nolan TW, Whittington J. The Triple Aim: care, health, and cost. Health Aff (Milwood). 2008;27(3):759-769.
7. Peikes D, Genevro J, Scholle SH, Torda P. The Patient-Centered Medical Home: Strategies to Put Patients at the Center of Primary Care. AHRQ Publication No. 11-0029. Rockville, MD: Agency for Healthcare Research and Quality. February 2011.
8. Engelberg Center for Health Care Reform, The Dartmouth Institute. The ACO Learning Network ACO Tool Kit. The Brookings Institution, Washington, DC. January 2011.
9. Eagle D, Sprandio J. A care model for the future: the oncology medical home. Oncology. 2011;25(7):571,575-576.
10. Centers for Medicare & Medicaid Services. Fact sheet: oncology care model. CMS website. https://innovation.cms.gov/initiatives/oncology-care/ Updated November 18, 2016. Accessed November 18, 2016.
