Collaboration Across Specialties to Improve Care and Curb Costs

In his presentation at CANCERSCAPE, Matthew A Manning, MD, Cone Health Cancer Center (Greensboro, NC), discussed how improved communication across medical departments can lead to improved outcomes for patients with cancer.

Dr Manning began by discussing the rising costs in oncology. Accounting for 91% of the increase in health care costs between 2000 and 2011 was an increase in the prices of drugs, medical devices, and hospital care. Dr Manning cited three specific factors as being largely responsible for the rise in oncology costs: (1) the increasing size of the population of elderly adults; (2) changing thresholds as a result of new diagnostics based on oncotype; and (3) innovations in the development of targeted treatments, such as Herceptin (trastuzumab) for the treatment of HER2+ breast and gastric cancers. Out of the nearly $374 billion spent on prescriptions in 2014, ~9% ($32.6 billion) was spent on oncology drugs. Another $11.1 billion was spent on supportive care treatments for the side effects of chemotherapy drugs.

Although there has been a great deal of scrutiny regarding these rising costs, not much has been done in the last 10 years to address them. Not one oncology medication is included in the top 20 most widely prescribed medications, indicating that the problem is due to the individual high prices of treatments.

Accountable care organizations (ACOs) are designed to help control costs. These groups of doctors, hospitals, and other health care providers come together voluntarily to give coordinated, high-quality care to Medicare patients. The goal of coordinated care is to ensure that patients, especially those with chronic illnesses, get the right care at the right time while avoiding unnecessary duplication of services and preventing medical errors. When an ACO succeeds both in delivering high-quality care and spending health care dollars more wisely, Dr Manning said, it will share in the savings it achieves for the Medicare program. The theory is that, if doctors and hospitals benefit from saving costs, they will be more like insurance companies and, thus, will start acting more like insurance companies; ie, restructuring the delivery of care to reduce redundancy, using data and analytics to identify both intuitive and non-intuitive opportunities, and studying their patients.

Because it is not possible for an ACO with more than 30,000 Medicare beneficiaries to study each patient to determine how to reduce costs for that patient, Dr Manning suggested focusing on smaller subgroups. But how to pick the right sub-population of patients is a subject of much debate. Although widely held assumptions dictate that oncology patients or patients with advanced disease should be the focus of study for reducing costs, Dr Manning suggests focusing on “hot-spotters,” or chronically sick people who account for the greatest percentage of the overall health care costs. 

Beginning with 1 year of claims data for 31,336 Medicare beneficiaries treated at the Cone Health Cancer Center, Dr Manning and his colleagues identified 3942 with a cancer diagnosis. Within this group, they defined a cohort of 216 hot-spotters as the 5% of patients who incurred claims totaling at least $50,000 each. This group was further narrowed down to 70 patients who had at least 3 cancer center visits during the study period, in order to ensure that health care utilization was closely tied to the patient’s cancer diagnosis.

Next, they sought to learn about why these costs were incurred. They carried out chart reviews to gather data regarding cancer type, cancer stage, treating oncologist, and detail about the treatments to build a clear profile of the patient population. They found a relatively even distribution of presenting cancer types across the patient population, with no predominant tumor type. Similarly, the patients were relatively evenly distributed across tumor stages. Versus a cancer registry population used for comparison, the hot-spotter population was significantly more likely to have a diagnosis of blood and bone marrow cancers and to have cancer of stage I, stage IV, or unknown stage. Still, these findings did not explain the cost differences for these patients.

Next, Dr Manning and his colleagues looked at how money for health care hot-spotters was spent. They found that 90% of the patients had emergency department visits, with a median of 4.5 ED visits per patient. Additionally, 60% of the patients were hospitalized, with some patients being hospitalized 9 times. The reasons for these hospitalizations seemed to be multiple comorbid health care conditions, most commonly congestive heart failure, chronic obstructive pulmonary disease, and renal failure. Additionally, a large percentage of costs were associated with patient death, which itself was closely tied with the likelihood of having an ED visit.

In order to address these sources of high costs, the team proposed developing a few different multidisciplinary interventions. In order to address common comorbidities associated with cancer treatment, they developed systems for “cross-silo” care, or coordination between the oncology care team and other departments. For example, because women with breast cancer who are treated with trastuzumab are at increased risk for congestive heart failure, these patients were prospectively referred to cardiology to be screened for cardiovascular risk factors and left ventricular ejection fraction dysfunction. To address the high costs associated with patient death, the team sought to avoid having patients turn to the ED for care, which often leads to death in the intensive care unit. Instead, a palliative care nurse practitioner program was integrated into the brain and spine clinic. The goals of care included development of advanced directives, discussion and potential documentation of Do Not Resuscitate (DNR) orders, and introduction of Medical Orders for the Scope of Treatment (MOST) forms. Enrollment in hospice occurred in 33.3% of patients. Overall, the program was associated with an estimated cost savings of $364,800.

The team next determined that high costs associated with hospital admissions and ED visits were related to inadequate management of patient symptoms, specifically pain. In order to address this, Dr Manning and his colleagues created a standardized triage phone assessment and established a symptom management clinic. Under the supervision of medical oncology, an advanced practice provider addressed patients’ pain and other symptoms of their disease as well as side effects associated with their treatment.

Other initiatives used by the team to reduce costs included promoting high-technology treatments, which are associated with fewer adverse events, and promoting better quality of care across the integrated care network, such as through the use of dashboards to track admissions, the establishment of multi-silo care teams to collaborate on complex patients, and the involvement of primary care physicians to coordinate care for complex patients.

Dr Manning concluded by stressing that, if providers do not work to control their own spending, payers are likely to intervene to control spending for them. Often, he added, these interventions are not as nuanced as those initiated by the providers themselves and may be less likely to protect the best interests of patients. To avoid this, he urged providers to monitor their costs and look for opportunities to cut costs without cutting revenue, such as by reducing ED and hospital visits, and to build multidisciplinary safety nets to provide the necessary supportive care to patients so that they will not have to rely on the ED and the hospital for care.