Abstract: Participants in the Oncology Care Model (OCM) have both the opportunity and need to drive performance by building upon strong historical foundations in oncology clinical pathways and by promoting outcomes for patients receiving chemotherapy. While a number of payment model modifications would be beneficial, such as those articulated through OCM 2.0, one involves integrating palliative care within OCM using clinical pathways. Several strategies can help participants achieve this goal, such as embedding automatically-triggering early palliative care consults, permitting parallel and potentially intersecting curative chemotherapy and palliative processes, and promoting education via patient-facing pathway materials.
As a leader in in the nationwide shift from fee-for-service toward value-based payment, the Centers for Medicare & Medicaid Services (CMS) has partnered with commercial insurers and implemented the Oncology Care Model (OCM) to reform how it pays providers for treating patients with cancer.1 This model bundles reimbursement around 6-month episodes defined by initiation of chemotherapy.
Clinical pathways—defined as structured, multidisciplinary care plans that incorporate evidence-based guidelines and protocols to standardize care2—represent a natural and potentially promising strategy for achieving success in OCM. As a payment arrangement, bundled payments are a “rising tide” that provide opportunity to improve the design and implementation of clinical pathways.3
Importantly, there is also a long track record of pathway work in the field of oncology. A 2012 study found that 507 active or pending cancer management models were being used or discussed in the United States; of those, 255 were actively running, and 222 of them included clinical pathways in their models.4 Early programs were focused on medical oncology, ie, drug treatment and regimen sequencing to deliver “cancer care for specific patient presentations, including the state and stage of disease. A regimen for treatment is specified, including the names of the drugs, dosing levels, and schedule for administration.”5 Pathways can include prognostic testing, chemotherapy, biologic therapy, supportive care, and radiation therapy. Via Oncology (now ClinicalPath, since acquired by Elsevier6) even created a pathway for end-of-life care in 2011.5 Pathway utilization continues to grow in many settings, with a 42% increase in clinical pathways use among oncology practices between 2014 and 2016.7,8 Pathways have also been described for surgical care of breast cancer,9-12 colorectal cancer,13 lung cancer,14 and prostate cancer.15
Despite these statistics, applying prior experience in oncology pathways may be insufficient for maximizing performance in OCM for a few reasons. Historically, many oncology pathways have focused on surgical aspects of cancer care rather than administration of chemotherapy, which is emphasized in OCM. Existing pathway frameworks may also fail to generalize to OCM, given that the program involves a unique format with episodes that can trigger on a rolling basis.
Therefore, practice leaders have an opportunity to prioritize new features in OCM-focused pathways to drive outcomes and performance. The imperative to do so is further heightened by concurrent efforts to improve oncology bundles via OCM 2.0,16 as well as policymaker interest in transitioning from voluntary to mandatory bundled payments in oncology.17 One major area of opportunity for improvement would be to incorporate palliative care into OCM via clinical pathways.
The Need for Greater Incorporation of Palliative Care Within OCM
The evidence for palliative care in the setting of oncology is clear: when administered alongside life-prolonging cancer treatment, specialized palliative care can reduce psychological distress and improve symptom management, quality of life, satisfaction with care, and survival.18-20
Despite these benefits, managing end-of-life care represented a point of tension among some OCM providers, as a decision to pursue curative treatment would mean enrollment in OCM while a decision to receive palliative care without chemotherapy would mean exclusion.21 Per CMS guidance, OCM participants “are expected to rely on the most current medical evidence and shared decision-making with beneficiaries to inform their recommendation about whether a beneficiary should receive chemotherapy treatment.” Yet, providers reported feeling caught in the awkward space of recommending chemotherapy at one visit and referring to end-of-life care modalities at the next.21
This tension demonstrates a pervasive trend in cancer care: the misunderstanding that decisions to pursue chemotherapy and need for palliation are mutually exclusive. Though palliative care is often synonymized with end-of-life care, it is in fact much broader, defined as:
[A]n approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problem, physical, psychosocial, and spiritual.22
Not only does palliative care improve outcomes and experience for patients, it has been shown to help optimize a transition from chemotherapy to hospice care when it becomes appropriate at the end of life.23
Ostensibly, the goal of OCM is to standardize and improve cancer care while optimizing the allocation of resources. We argue that one key way to support these goals is to integrate palliative care elements into clinical pathways that are implemented in service of OCM. This integration would complement other relevant changes, as proposed in OCM 2.0,16 and could be operationalized in three ways.
How to Use Pathways to Better Incorporate Palliative Care Into OCM
First, OCM-directed pathways could involve an automatic palliative care consult for all patients at the beginning of their first episode. Doing so, regardless of patients’ stage of disease, would not only normalize and systematize early conversations about goals of care but also help clarify the misconception that palliative care is synonymous with hospice. For patients with early stage disease, palliative care may focus primarily on symptom management and psychosocial support, both of which are important considerations for all patients undergoing cancer treatment. Because implementation of these services would depend on provider supply, providers and policymakers could work to provide the aspects of palliative care most salient to patients with early stage disease while also considering if and how to meet patient needs by workforce augmentation.
If and when emphasis needs to be shifted to end-of-life measures, the transition would be aided by an existing relationship between a palliative care provider and the patient, their family, and their primary oncologist. These relationships could be particularly important for improving the consistency of advanced care planning, which remains suboptimal in some settings. For example, in some instances, end-of-life discussions have been reported by only a third of dying cancer patients approximately 4 months before death.24
Second, pathways implemented to support OCM could be structured to allow for simultaneous chemotherapy and palliation to continue across the 6-month episode. It is not unusual for patients to trial one round of therapy and then transition to end-of-life care. Therefore, pathways could incorporate flexibility to allow multidisciplinary care teams to shift between different patient goals over time. Not only would this allow for constructive co-management of cancer patients, but it would also relieve provider tensions described above around the timing of a palliative care consult.
Finally, OCM-directed pathways could incorporate patient-facing materials as elements to educate patients about the role of palliative care in oncologic care. While the two suggested changes above indirectly communicate a message and culture about a more comprehensive approach to palliative care, patient education can provide direct reinforcement about the importance of such an approach. Above and beyond helping to improve patients’ OCM experience and outcomes, widespread use of these education elements would help bridge the divide that still exists between patient-focused care and tumor-focused care in some clinical settings.
Conclusion
The emergence of OCM has created both the opportunity and need to build upon historical foundations in oncology clinical pathways and promote patient outcomes and organizational success in bundled payments centered on chemotherapy. A number of modifications would be beneficial, including using clinical pathways to better incorporate palliative care into the payment model. Several strategies can help OCM participants achieve this goal, including embedding automatically-triggering early palliative care consults, permitting parallel and potentially intersecting curative chemotherapy and palliative processes, and promoting education via patient-facing pathway materials.
References
1. Centers for Medicare & Medicaid Services. Oncology Care Model. https://innovation.cms.gov/initiatives/oncology-care/. Updated September 11, 2019. Accessed October 24, 2019.
2. Kinsman L, Rotter T, James E, Snow P, Willis J. What is a clinical pathway? Development of a definition to inform the debate. BMC Med. 2010;8:31. doi:10.1186/1741-7015-8-31
3. Liao JM. Bundled payments: a rising tide for clinical pathways. J Clin Pathways. 2018;4(10):58-60. doi:10.25270/jcp.2018.12.00051
4. Schroeder A. Clinical pathways: a current snapshot, and the journey ahead. J Clin Pathways. 2017;3(2):33-40.
5. Gesme DH, Wiseman M. Strategic use of clinical pathways. J Oncol Pract. 2011;7(1):54-56. doi:10.1200/JOP.2010.000193
6. Elsevier. ClinicalPath (formerly Via Oncology). https://www.elsevier.com/solutions/clinicalpath. Accessed October 24, 2019.
7. American Society of Clinical Oncology. The state of cancer care in America, 2017: a report by the American Society of Clinical Oncology. J Oncol Pract. 2017;13(4):e353-e394. doi:10.1200/JOP.2016.020743
8. Daly B, Zon RT, Page RD, et al. Oncology clinical pathways: charting the landscape of pathway providers. J Oncol Pract. 2018;14(3):e194-e200. doi:10.1200/JOP.17.00033
9. Santoso U, Lau PT, Lim J, Koh CS, Pang YT. The mastectomy clinical pathway: what has it achieved? Ann Acad Med Singapore. 2002;31(4):440-445.
10. Richter-Ehrenstein C, Heymann S, Schneider A, Vargas Hein O. Effects of a clinical pathway 3 years after implementation in breast surgery. Arch Gynecol Obstet. 2012;285(2):515-520. doi:10.1007/s00404-011-1994-7
11. Tastan S, Hatipoglu S, Iyigun E, Kilic S. Implementation of a clinical pathway in breast cancer patients undergoing breast surgery. Eur J Oncol Nurs. 2012;16(4):368-374. doi:10.1016/j.ejon.2011.07.003
12. Van Dam PA, Verheyden G, Sugihara A, et al. A dynamic clinical pathway for the treatment of patients with early breast cancer is a tool for better cancer care: implementation and prospective analysis between 2002-2010. World J Surg Oncol. 2013;11:70. doi:10.1186/1477-7819-11-70
13. Ishiguro S, Yamamoto S, Fujita S, Akasu T, Kobayashi Y, Moriya Y. Effect of a clinical pathway after laparoscopic surgery for colorectal cancer. Hepatogastroenterology. 2008;55(85):1315-1319.
14. Maruyama R, Miyake T, Kojo M, et al. Establishment of a clinical pathway as an effective tool to reduce hospitalization and charges after video-assisted thoracoscopic pulmonary resection. Jpn J Thorac Cardiovasc Surg. 2006;54(6):387-390.
15. Konety BR, Painter L, Bahnson RR. A cost containment strategy for radical retropubic prostatectomy: results from implementation of a clinical pathway program. Urol Oncol. 1996;2(3):80-87.
16. Dangi-Garimella S. COA’s OCM 2.0: moving toward a universal payment model. Am J Manag Care. October 30, 2018. https://www.ajmc.com/conferences/coapayersummit2018/coas-ocm-20-moving-toward-a-universal-payment-model. Accessed October 24, 2019.
17. Caffrey M, Inserro A. Azar announces mandatory oncology payment model is coming. Am J Manag Care. November 8, 2018. https://www.ajmc.com/newsroom/azar-announces-mandatory-oncology-payment-model-is-coming. Accessed October 24, 2019.
18. Temel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med. 2010;363(8):733-742. doi:10.1056/NEJMoa1000678
19. Jordhøy MS, Fayers P, Loge JH, Ahlner-Elmqvist M, Kaasa S. Quality of life in palliative cancer care: results from a cluster randomized trial. J Clin Oncol. 2001;19(18):3884-3894.
20. Zimmermann C, Swami N, Krzyzanowska M, et al. Early palliative care for patients with advanced cancer: a cluster-randomised controlled trial. Lancet. 2014;383(9930):1721-1730. doi:10.1016/S0140-6736(13)62416-2
21. Saunders C. The Oncology Care Model performance period 2 results: practices are making some progress, but major challenges remain. J Clin Pathways. 2018;4(10):53-57. doi:10.25270/jcp.2018.12.00050
22. World Health Organization. WHO Definition of Palliative Care. https://www.who.int/cancer/palliative/definition/en/. Accessed October 24, 2019.
23. Greer, JA, Pirl WF, Jackson VA, et al. Effect of early palliative care on chemotherapy use and end-of-life care in patients with metastatic non-small-cell lung cancer. J Clin Oncol. 2011; 30(4):394-400. doi:10.1200/JCO.2011.35.7996
24. Wright AA, Zhang B, Ray A, et al. Associations between end-of-life discussions, patient mental health, medical care near death, and caregiver bereavement adjustment. JAMA. 2008;300(14):1665-1673. doi:10.1001/jama.300.14.1665
