In Cancer Care, Turning Attention to Transitions, SDOH

What Joseph Alvarnas, MD, calls “the patient journey” in cancer treatment is never easy, but it is less perilous if each step makes sense, if patients are not left to find their own way from appointment to appointment, and if someone thinks about their other problems—like days of work being missed or food not coming into the house.

Alvarnas, a hematologist/oncologist at City of Hope in Duarte, California, and co-chair of Patient-Centered Oncology Care® 2021, presented by¨The American Journal of Managed Care®, moderated a panel that discussed what more can be done in this area—with the goal of improving patient outcomes—in¨“Oncology Care Transitions: Bridging the Gaps Across the
Patient Journey.” It featured:

• KENNETH COHEN, MD, FACP,¨senior medical director and executive director, Clinical Research, national senior medical director, Optum Care in Golden, Colorado;
• RYAN HAUMSCHILD, PHARMD, MS, MBA,¨director of pharmacy
services, Winship Cancer Institute, part of Emory Healthcare in Atlanta, Georgia;
• KRISTA NELSON, MSW, LCSW, OSW-C,¨program manager for quality and research of the Cancer Center, Providence Health Services in Portland, Oregon; and the current president of the Association of Community Cancer
Centers (ACCC); and
• SIBEL BLAU, MD,¨partner and medical director of Northwest Medical Specialties, PLLC, in Puyallup, Washington, and president and CEO of the Quality Cancer Care Alliance (QCCA).

Throughout the session, Alvarnas and the panelists addressed a conundrum in cancer treatment: The rise of care navigation has been a game changer for patient satisfaction and better outcomes, yet adequate reimbursement for this service can be elusive.

“I have a lot of opinions on that,” said Nelson, who has made the need for health equity a theme of her term as ACCC president. She referred the audience to the 2019 National Academies of¨Medicine¨report, Integrating Social Care into the Delivery of Health Care, and said that ensuring good health outcomes in cancer care requires the health system to address social determinants that can affect care—such as access to food, housing, or¨transportation.¹

“Social workers, navigators, physicians—you are experts in the lived experiences of our patients, and how they’re suffering, the things that impact their life,” Nelson said.

Nelson called for 3 elements to address social determinants of health (SDOH) in cancer care: First, it’s essential to have someone who is addressing barriers to care, including a person’s ability to take part in clinical trials; second, there must be data sharing between social support services and health care; and finally, Medicare and Medicaid must offer incentives to those health care organizations that are working with community partners who address social care issues.

Blau described how the QCCA rose out of the need for community practices to share data and resources to develop care navigation strategies—specifically to meet requirements of the Oncology Care Model (OCM)—along with other value-based care strategies. Better technology was at the top of the list.

Being part of a bigger network allows practices to accomplish goals like negotiate discounts and gain access to richer data sources. “As part of this organization, we have the ability to expand and do certain things we couldn’t do on our own,” Blau said.

It’s part of what Cohen called medicine’s evolution. “For decades, medicine has been a cottage industry, and it really can’t advance if it’s going to continue to be a cottage industry,” he declared. “So, a certain amount of practice consolidation needs to occur to develop the [information technology] infrastructure, to be able to measure outcomes and drive change.

“Now, that doesn’t mean you’ve got to be acquired by a hospital,” Cohen said. “But you do need to coalesce into a unit that’s large enough [to allow] you to activate and get meaningful results.”

“Meds to Beds” Boosts Adherence
Haumschild offered examples of how the pharmacy at Winship has thought through the process of discharge and the clinic visit, eliminating steps for the patient or caregiver and reducing opportunities for missed medications. If there are any missteps in these handoffs, he said, “the patients do suffer.”

During a clinic visit, oral medications are delivered to the infusion chair so the patient can take them home. The in-house specialty pharmacy has also been highly successful with its “meds to beds” initiative, which delivers the retail prescriptions to the patient being discharged before they go home.

“It’s so important that we keep on top of their medication and that they leave with the right medication,” Haumschild said.

Compared with patients whose insurance has a pharmacy benefit manager that requires the patient to receive drugs elsewhere, the patients using the in-house specialty pharmacy have 25% higher medication adherence, noted Haumschild.²

Paying for What Works
Cohen said a flaw with the OCM is that it is still not a full risk model and does not fully reward practices that invest in areas like addressing social determinants—or deciding not to aggressively treat nonlethal malignancies. Using a nononcology example, Cohen said payers are slowly realizing that they paid for expensive spinal procedures but wouldn’t pay for patients to take sessions in tai chi or Pilates “that actually work.”

Part of improving care transitions will be letting practices assume the risk for the whole treatment approach. Nelson noted that practices and health systems will find that a social worker, for instance, is a relatively low-cost investment with a significant return.

Where Can Industry Help?
Alvarnas asked where the pharmaceutical industry can be a partner in eliminating care gaps. Nelson pointed to the issue of cost, especially with chimeric antigen receptor T-cell therapies that cause both patient and
caregiver to miss 30 days of work—although she said she thought that in general, during the trials, industry did a good job.

Said Haumschild, “I see the industry as a partner in patient care.…When we’re working together, patients actually benefit the most.” He offered an example of how CDK4/6 inhibitors were not being prescribed to some groups of patients at his cancer center, due to physician concerns about toxicity. Haumschild received data from industry and discussed dosing options.

“I was able to take those data back, internally validated, and bring it to our physician group,” Haumschild said. Through the discussions, the physicians were able to come up with care plans and dosage reductions for certain groups. A year later, he said, the data show that prescribing of CDK4/6 inhibitors has improved in the population, which means these patients are receiving the best practice therapy with reduced adverse effects.

Cohen said industry can help by following through on phase 3 trials for therapies that reach the market under accelerated approvals and by publishing pharmacoeconomic studies “to show the cost of any meaningful clinical improvement and see how it compares with other therapies.” And he asked that industry answer the most basic questions posed by oncology patients: Will I live longer, and will I feel better?

References

1. National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Health Care Services; Committee on Integrating Social Needs Care into the Delivery of Health Care to Improve the Nation’s Health. Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation’s Health. National Academies Press;
2019. doi:10.17226/25467
2. McCabe CC, Barbee MS, Watson ML, et al. Comparison of rates of adherence to oral chemotherapy medications filled through an internal health-system specialty pharmacy vs external specialty pharmacies. Am J Health Sys Pharm. 2020;77(14):1118-1127. doi:10.1093/ajhp/zxaa135