Optimizing Medicaid for Cancer Patients

Federal policy on clinical trial coverage must bring Medicaid up to speed with Medicare, private ACA counterparts

By Steve Lee, MD

Dr. Steve Lee

Dr. Steve Lee

The status of Medicaid remains firmly in the news, with ongoing political and legal questions regarding hot-button issues such as work requirements that have far-reaching implications on access to care. On the oncology front, Medicaid access made waves at the 2019 ASCO Annual Meeting, with an abstract meriting plenary session placement.

The Flatiron Health and Yale study analyzed electronic medical records of over 34,000 patients in the Flatiron database before and after the 2014 expansion of Medicaid via the Obama-era Patient Protection and Affordable Care Act (PPACA).  Most notably, in the post expansion era, African Americans were as likely as their white counterparts to receive first line treatment within 30 days of diagnosis whereas prior to the expansion African Americans were 4.9 percentage points less likely to receive timely treatment. These findings suggest that political decisions which increase access to health coverage can improve the delivery of cancer care, particularly among underserved populations.

I have found this to be true in my former role as an oncologist at Bellevue Hospital Center in New York City. The flagship of New York City's municipal health system, Bellevue receives and treats patients with complex cancer diagnoses regardless of insurance or legal status. Through a unique partnership with New York University as well as its Perlmutter Cancer Center, an NCI-designated Comprehensive Cancer Center, my Bellevue patients had access to a diverse portfolio of clinical trials.

 In other parts of the country, however, Medicaid expansion does not necessarily allow for enrollment and potential benefit from clinical trials.  While Medicare and the vast majority of post-ACA private health insurance plans cover the routine costs of care for patients on clinical trials, these protections do not include Medicaid.  Only twelve states independently cover these charges  which would be incurred regardless of trial status - these include regular appointments, imaging, medications, and hospitalizations; study drugs and study-specific testing are typically covered by the trial sponsor.  Interestingly, New York is not one of these twelve states, and they and 42.2 million Medicaid recipients in the other 37 states may not have access to potentially life-changing clinical trials.

 In response, ASCO has teamed up with other patient advocacy organizations to support H.R. 913, the Clinical Treatment Act. With bipartisan co-sponsors including Rep. Ben Ray Lujan (D-NM) and Rep Gus Bilirakis (R-FL), the bill would bring Medicaid protections up to speed with its Medicare and ACA exchange counterparts. The Flatiron Health and Yale study highlights the promise and potential of reducing disparities through expanded Medicaid while enhancing Medicaid protections in the clinical trial space could lead to greater inclusion in clinical trials and subsequently foster more generalizable research findings.

 While a step in the right direction, H.R. 913 does not promise a solution to all payment-related barriers to clinical trial enrollment. Despite health insurance coverage of medical costs, many patients face onerous out-of-pocket costs such as increased travel expenses and co-pays that restrict the ability to participate in clinical trials. Further, oncologists have found therapy hampered by restrictive prior authorizations and other red tape that can prevent enrollment in a clinically relevant timeframe. In response, ASCO convened a 2017 Roundtable to address the real patient-facing costs of clinical trial research, with policy recommendations. H.R. 913 has not yet received a budget score, though proponents suggest a minimal effect on total health care spending, as routine costs of care are likely to be incurred whether or not a patient is on a trial. After introduction in January 2019, the bill remains in Committee.

JOP DAiS encourages discussion and welcomes your comments. Please note that comments are moderated; inappropriate remarks will not be tolerated.

If you have questions for our editors or have a submission inquiry please contact jopcontact@asco.org.  

 

The Four Pillars of an Ideal Two-sided Risk Value-based Payment Model in Medical Oncology

Aaron J. Lyss, MBA. Director of Strategy and Business Development, Tennessee Oncology, Nashville, TN

Tracy L. Bahl, MBA. President and Chief Executive Officer, OneOncology, Nashville, TN

Jeffrey F. Patton, MD. Chief Executive Officer, Tennessee Oncology; President of Physician Services, OneOncology, both in Nashville, TN

Stephen M. Schleicher, MD, MBA. Medical Oncologist, Tennessee Oncology, Nashville, TN

 

Value-based payment models (VBPMs), which aim to incentivize the highest quality care at the lowest possible cost, have become increasingly prevalent in oncology in recent years among commercial and publicly-funded payers in the US.[1] Several recent federal policy initiatives implemented by the Centers for Medicare and Medicaid Services (CMS) have explicitly aimed to spur the growth of VBPMs, including the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), which incentivizes providers to participate in alternative payment models, and the Oncology Care Model (OCM), which is the largest cancer-specific VBPM with 176 medical oncology physician groups (MOPGs) participating in the upside-only (indicates no risk) option.

One challenge CMS has faced with OCM is sufficiently incentivizing MOPGs to voluntarily elect to participate in the two-sided risk option. Under two-sided risk, performance-based payments accrue to MOPGs if they generate greater than 2.5% total Medicare cost savings relative to projected benchmark costs for their attributed patient population, while financial penalties are imposed on MOPGs if total costs are higher than Medicare’s benchmarks. As of today, not a single oncology practice has opted for participation in the OCM two-sided risk option.

Beginning in January of 2020, practices who have not earned performance-based payments will be forced to either exit the model or accept mandatory two-sided risk. Therefore, we found it timely to present a framework to define an ideal two-sided risk model for oncology. Here we describe four fundamental pillars (see Figure 1) of VBPM design that are critical to supporting what we believe are the four primary objectives of VBPMs (higher quality, better access to care, lower costs, better patient experience), and creating value for payers, MOPGS, and most importantly our patients.

Figure 1:  The four pillars of an ideal two-sided risk oncology value-based payment model.

Figure 1: The four pillars of an ideal two-sided risk oncology value-based payment model.

The four fundamental pillars of VBPM design

I.  Aligning control and accountability  

MOPGs should be held accountable for measures of quality that are within their control. There are two subcategories of quality metrics that are especially important to consider in the design and implementation of VBPMs: (1) pathway adherence; and (2) care-coordination related utilization measures.

(1) Appropriate drug utilization should be measured through clinical pathway adherence, not total dollars spent

VBPMs should ensure that patients have access to the most effective therapies for their conditions, and that patients receive treatments that are consistent with their personal goals of care.

MOPGs can control their treatment decisions and should be held accountable for concordance of treatment decisions with clinical pathways. However, MOPGs cannot control the prices of treatments used. Therefore, MOPG accountability for appropriate drug utilization should not be measured by the total dollars spent by payers for patients with cancer, and instead should be measured by clinical pathway adherence provided that the following conditions are met:

 

        1. MOPGs should maintain documentation of physician and patient attestation that treatment decisions were made through a process of shared-decision making. Documentation of the shared-decision making process is critical to ensuring that the treatments patients receive are consistent with their personal goals of care, and that patients are appropriately informed of the risks associated with the treatment they elect to receive.

           

        2. Clinical pathways are updated in real-time based on groundbreaking clinical trial data and FDA approvals, and consider clinical and financial toxicity when appropriate. Pathways should be expert designed and conflicts of interest should be transparent.

           

        3. Physicians should document a reason for any off-pathway treatment decisions.

           

(2) Measured performance outcomes should reflect improved care coordination

Two-sided risk VBPMs should tie MOPG reimbursement to the measurement of outcomes in care-coordination-related utilization categories, since these are metrics that can be influenced (and hence controlled) through the implementation of practice improvement efforts by MPOGs. Studies have shown that the utilization of care-coordination related utilization such as inpatient hospital, emergency department, and inpatient post-acute care services vary widely across MPOGs and represent appropriate measures of high quality, well-coordinated cancer care across a wide variety of tumor types. [ii]

In contrast, reduction in payer drug spending has not been reliably correlated to high quality care, and therefore MOPGs should include distinct compensation thresholds for drug utilization vs.  care-coordination related utilization in two-sided risk VBPMs.[iii], [iv]

II. Accurate benchmarking

At the core of any VBPM is the methodological considerations that create accurate performance benchmarks for participating MOPGs. However, accurate benchmarking in cancer is complicated by the heterogeneity and rising costs of cancer treatments over time.

First of all, due to limitations of claims data, the OCM and many commercial payer VBPMs include drug cost benchmarks that do not consider cancer stage or specific cancer histology. For example, none of the 31 ICD-10 codes for the lung cancer disease grouping of OCM differentiate between non-small cell lung cancer and small cell lung cancer.

However, these distinctions, as well as tumor stage and biomarkers, are critical to determining optimal treatment strategies and expected disease complications that influence reliable benchmarks.[v] For example, the treatment and prognosis of non-small cell lung cancer (which may include surgery) and small cell lung cancer (which often includes prophylactic brain radiation) can vary widely. In contrast, medical oncology clinical pathway development is based on the most important clinical characteristics that drive treatment decisions.

Secondly, accounting for increases in regimen costs due to FDA approvals that occur after baseline periods further complicates the accuracy of benchmarking drug costs. For example, the recent approval of atezolizumab in combination with Nab-paclitaxel in metastatic triple negative breast cancer increased the cost (based on January 2019 average sales price) of the first-line standard-of-care triple negative breast cancer regimen by more than 250-fold compared to the previous standard-of-care treatment single agent weekly paclitaxel.

Therefore, benchmarking MOPGs according to pathway adherence (assuming pathways are updated in realtime based on groundbreaking clinical trial data and FDA approvals) instead of total drug spend may minimize the adverse impact of rising drug prices on the ability for MOPGs to meet benchmarks.

 

III. Bilateralism

When MOPGs participate in VBPMs in which accountability and control are aligned, the next step is determining the equitable compensation for value creation and appropriate financial incentive for taking on risk.  

OCM will offer an interesting case study on bilateralism in the coming years. Last fall OCM participants were faced with the decision of whether to enter the two-sided risk option of OCM or remain in the upside-only option. Using prior performance period data and the newly proposed OCM two-sided risk option specifications, we conducted financial modeling that projected that the maximum possible downside of the two-sided risk option would be approximately 41x the most likely revenue increase (i.e. upside) associated with our two-sided risk participation (see Table 1).

Table 1:  Downside multiplier change based on different model choices.

Table 1: Downside multiplier change based on different model choices.

Therefore, the risk premium (the most probable increase in revenue from entering two-sided risk) was deemed minimal compared to the magnitude of possible losses, which offers a likely explanation for why OCM participants have been reluctant to enter two-sided risk in its current form.

However, in January 2020 OCM participants will be faced with a different decision: to enter two-sided risk or exit the OCM program altogether. When comparing these two options, the maximum possible downside of entering the two-sided risk would be only 5x the risk premium. This improved downside multiplier (maximum downside divided by risk premium) results from the loss of MEOS revenue for MOPGs that exit the OCM model. In effect, MEOS payments become part of the risk premium for the two-sided risk model (since the only alternative is to exit OCM altogether at that point). This dramatic increase in risk premium will likely increase the number of OCM participants who opt to participate in two-sided risk; however, it is unclear whether this increased risk premium will be sufficient to prevent high-quality, low-cost MOPGs from exiting the model in order to avoid higher levels of risk.

 

IV. Scalability

Nationwide proliferation of VBPMs requires that VBPMs be operationally scalable for payers who manage these programs. For example, the permeation of bundled payments in oncology has been partially hampered by challenges with scaling claims processing.[vi] In addition, MOPGs and payers alike have not yet benefited from technology-enabled pathway adherence and clinical data reporting capabilities that are scalable for either party.

To address the remarkable complexity of medical oncology, payers must work closely with thought leaders who are currently engaging in oncology VPBMs to learn from successes and challenges of current VBPM experiments and to make these insights publicly available. This transparency would catalyze an evidence-based approach to VBPM design and implementation, and prevent nationwide expansion of sub-optimized payment models that fail to engage providers and improve the value of care for our patients.

 

Concluding remarks:

The current economics of cancer care in the US are placing an unsustainable strain on our healthcare system. At the same time, payer pressures were cited as the top concern among oncologists in the most recent “State of oncology practice in America, 2018” survey results.[vii] We hope that appropriate VBPM design that incorporates the four pillars described above will mitigate these challenges to our current system of cancer care and lead to higher quality, lower costs, improved access, and better patient experience for our patients.


REFERENCES:

 

[1] Aviki E, Schleicher SM, Mullangi S, et al. Value-based healthcare delivery models in oncology: A systematic review. Cancer 124(16): 3293-3306, 2018.  

[ii] Clough JD, Patel K, Riley GF, et al. Wide variation in payments for Medicare beneficiary oncology services suggests room for practice-level improvement. Health Aff (Millwood) 34(4): 601-608, 2015.

[iii] Newcomer et al. Changing Physician Incentives for Affordable, Quality Cancer Care: Results of an Episode Payment Model. J Oncol Pract 10(5): 322-326, 2014.

[iv] Schleicher SM, Bach PB, Matsoukas K, Korenstein D. Medication overuse in oncology: current trends and future implications for patients and society. Lancet Oncol 19(4): 200-208, 2018.  

[v] Zon RT, Edge SB, Page RD, et al: American Society of Clinical Oncology criteria for high-quality clinical pathways in oncology. J Oncol Pract 13: 207-210, 2017.

[vi] Spinks T, Guzman A, Beadle BM, et al. Development and feasibility of bundled payments for the multidisciplinary treatment of head and neck cancer: A pilot progam. J Oncol Pract 14(2): 103-112, 2018.

[vii] Kirkwood MK, Hanley A, Bruinooge SS, et al: The state of oncology practice in America, 2018: Results of the American Society of Clinical Oncology Practice Census Survey. J Oncol Pract 14(7): 412-420, 2018.

 

The SUPPORT for Patients and Communities Act: A Partial Response Against the Opioid Epidemic

2018 Bipartisan Opioid Package Offers Mostly Indirect Effects on Patients With Cancer

By Steve Lee, MD

In a rare act of bipartisanship, the 115th Congress overwhelmingly adopted The Substance Use- Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act, which was subsequently signed into law by President Donald Trump on October 24, 2018.  This legislation was welcomed in the context of the alarming increase in opioid harms in the United States, reaching 72,000 deaths in 2017.

While broadly covering topics from increasing the availability of addiction specialists to securing insurance coverage for patients with opioid abuse to encouraging research into non-addictive alternatives for pain, a consensus among analysts is that while the legislative achievement is laudable, the SUPPORT Act ultimately fails to deliver a comprehensive response against the nation's opioid crisis.  Specifically, the bill does not allocate game-changing new funding in the manner employed against the HIV/AIDS epidemic in the 1990s.

And what about cancer patients, whose legitimate needs for potentially high levels of pain control often become collateral damage in wider efforts to curb opioid abuse?  In the past, cancer advocates such as ASCO have identified concerns related to interventions including intentionally difficult prior authorizations, prescribing caps, supply limits, and prescriber punishment as factors that can prevent cancer patients from getting the pain treatment they need. And this is in the context of overreaching contemporary Centers for Disease Control (CDC) opioid guidelines, at least in the opinion of 300+ clinicians in a recently submitted letter.

Fortunately (or unfortunately), the limited reach of the SUPPORT Act against the opioid crisis as a whole limits its harms to cancer patients.  Text of the statute as well as in summary are available.  (Section numbers in parentheses)

The SUPPORT Act calls for a Centers for Medicare & Medicaid Services (CMS) demonstration project in five to ten states which would provide an enhanced federal match for state Medicaid expenditures for substance use disorder (SUD) and recovery (1003).  Nationally, it expands Medicaid access to at-risk populations including post-incarceration juveniles and foster youths (1001) and pregnant/postpartum mothers (1002), and gives states the option for short-term coverage of adults who may have previously been ineligible due to care in Institutions for Mental Diseases (IMD) (5052).  Further, it enforces payment parity in state Children's Health Insurance Programs (CHIP) for SUDs as compared to treatment of physical disease (5022).

To increase access to SUD specialists, the law temporarily widens the pool of medication-assisted therapy (MAT) providers to include waiver-granted clinical nurse specialists, certified nurse midwives, and certified registered nurse anesthetists, who can treat 100 patients each; physicians can treat 275 patients each (3201).  MAT-training grants are authorized, but not specifically funded (3203).  Individual and system-based efforts to incentivize participation include a six-year loan repayment program for SUD clinicians in high-need areas (7071) as well as grants to Federally Qualified Health Centers (FQHC) and Rural Health Clinics (RHC) to offset the cost of MAT training (6083).  It also clarifies (1009) and reduces barriers to payment (2001) and registration (3232) for SUD telemedicine.

On regulation of the opioid supply, the SUPPORT calls for state-level Medicaid drug utilization review (1004), as well as identification of drug orders at risk for diversion through the Automated Consolidation Ordering System (ARCOS) for manufacturers (3271-3274), reporting and databasing of suspicious DEA registrants (3291-3292), and $75 million for outreach grants to outlier prescribers (6062).  By fall 2020, HHS must notify clinicians identified as being outlier opioid prescribers; notably, prescriptions to patients on hospice or with a cancer diagnosis may be exempted from analysis.  For security, all DEA Schedule II-V prescriptions to Medicare Part D or Medicare Advantage patients must be transmitted via electronic prescription by 2021, with waivers for "reasonable technical limitation" (2003).  Opioid quotas are clarified, and the DEA must justify liberalization of future caps in terms of public health benefits (3281-3282).

Illicit drugs are addressed by giving the Department of Health and Human Services (HHS) the authority to recall or bar drugs (3012) or distributors (3013) found to cause harm and strengthens coordination between the FDA and Customs and Border Control to detect the international entry of substances (3014); this is paid for by new customs fees and international charges (8002, 8005).  On the local level, the law authorizes grants to state and local agencies to detect fentanyl and other synthetic opioids (7011).

Measures to prevent overreach includes prohibition of Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey questions about pain management that don't take into account discussion of opioid risks and alternatives (6104).  Further, HHS and the Attorney General must present a report to Congress on the impacts of state and federal opioid prescribing limits (7024) - which may demonstrate unanticipated consequences.

A politically significant curiosity includes expansion of the CMS Open Payments (Sunshine Act) registry in 2022 to include physician assistants, nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists, and certified nurse midwives (6111).

Ultimately, the SUPPORT Act lays building blocks for a comprehensive opioid program, and does not obviously impair the practice of oncology.  Politically realities pending, more substantial future efforts may include votes on the Comprehensive Addiction Resources Emergency (CARE) Act sponsored by Sen. Elizabeth Warren and Rep. Elijah Cummings.  Modeled on the Ryan White Act of 1990 to combat the HIV/AIDS epidemic, the CARE Act would direct $100M against opioid harms. As promising as this and related initiatives may be, new legislation must be well-vetted by oncology advocates to avoid restrictions which may cause unanticipated harm to cancer patients.

 

The Hospital at Home: A Bright Prospect for Oncology Care?

by Heather Hylton, MS, PA-C

For many oncology patients, the home setting is typically a place for recovery following treatment for cancer or complications of cancer.  At times, this recovery is supported with formal home care services such as nurse and physical therapy visits, home health aide assistance, infusion services, and so forth.  These home care services may or may not be paid for by public and private payers.

“Hospital-at-home” programs enable patients to receive acute care in the home setting.  The general model for these programs consists of a multidisciplinary or interdisciplinary team who follows the patient closely and provides the needed medical services, including patient visits, in the patient’s home.  These programs have been implemented internationally and have demonstrated success in reducing complications and the cost of care while maintaining safe and effective care delivery and enhancing patient and caregiver satisfaction.

Implementation of the hospital-at-home model in the United States has been more limited although Johns Hopkins established this model over two decades ago, and their outcomes mirror the successes of international implementations.

Could the hospital-at-home model be feasible for oncology care such as administering chemotherapy here in the United States?  It seems there is real opportunity for such a program at the crossroads of patient and caregiver experience, optimization of physical facility capacity and utilization, and cost containment.

To bring this paradigm to oncology would require a number of points to be addressed:

  1. Payer policy. In general, payers have had limited agility to adapt to/address payment for innovative care-delivery models such as the hospital at home.  With ongoing efforts in payment reform and a heightened focus on value-based care over fee-for-service, there is opportunity to elevate the importance of this kind of model and determine fair payment practices.

  2. Adoption and referral. The success of any kind of program such as the hospital at home requires broad acceptance of the model and the timely and appropriate referral of patients to the program.  Clarity on how to refer and simplicity in the referral process itself are requisite.  Clear information on how safety and quality of care will be maintained and what metrics will be followed will be key to illustrating the value proposition of this care-delivery model.  In addition, establishing rigorous screening and selection criteria to determine appropriate cohorts of patients to participate in the program will be paramount.  Understanding, acknowledging, and addressing stakeholder concerns is essential to implementation and scaling of the program.   

  3. Close coordination and availability of services.  With the hospital-at-home model being a surrogate for hospital/outpatient facility delivery of medical services, the supplies and services needed to provide this care at home must be readily available and able to be rapidly deployed.  Implementation of the hospital-at-home paradigm may be more challenging in resource-limited settings where vendors or general availability of services may be sparse and geography over which those services are provided are more expansive.

  4. Patient and caregiver buy-in.  The hospital-at-home construct has repeatedly shown patient and caregiver satisfaction with the model.  From a practical standpoint, providing care in the home may serve to empower patients and the familiarity of the environment of care may be a source of comfort.  While studies have shown decreased complications such as delirium and falls in this model, proper and pertinent patient and caregiver education and ongoing engagement is key. 

  5. Optimizing technology. Leveraging technology, such as telemedicine, to enhance monitoring of patients in hospital-at-home programs is key.  This may also be a keen opportunity to incorporate patient-reported data and other innovations.  

  6. Appropriate pilot studies.  While extension of hospital-at-home services to oncology seem apparent, data on safety, feasibility, and cost in this patient population are limited.  CMS and private payers should be encouraged to support studies of this model in the oncology setting.

The hospital-at-home model for oncology patients offers high potential for patient convenience and satisfaction and lower cost compared with traditional inpatient care.  To scale such a model for oncology patients may bring yet another opportunity for unconventional partnerships thinking outside of the box and leading innovation in the health care space.

 

 

 

 

Shake Off the Tinsel: Five Innovations in Oncology Care Delivery to Watch in 2019

Robert M. Daly, MD

The start of a new year brings with it the promise of change. With the ongoing national shift from volume-based to value-based reimbursement, health care and oncology care have seen this shift ignite innovation that is leading to care transformation. As the landscape for care delivery shifts it is impacting all stakeholders including providers, payers, and most importantly, patients, and will hopefully lead to improvements in the quality of care.

These are five innovations to look for in 2019 in oncology care delivery that hold promise for positively disrupting the way we practice:

  1. Predictive analytics and artificial intelligence: Health care institutions and practices are just starting to leverage the richness of their electronic health record data to predict risk. These data driven models could have an impact in many different areas of oncology care including antineoplastic treatment decisions, early symptom identification and management, and identifying those at risk for acute care. However, currently these models are in their early stages and there is a need to better understand how these models impact care, including their unintentional consequences on clinician decision making, and how they can best be integrated into clinical practice. In addition, as third parties enter this space, such as Google and others, understanding how this data is monetized and who benefits from it will be essential decisions that institutions and practices will need to make. The ownership of extracting this data and leveraging it for clinical decision making will be a key competitive advantage for institutions and practices.

  2.  Patient-reported outcomes, 2.0: At the ASCO plenary session in 2017, Ethan Basch presented the survival results of his foundational clinical trial evaluating patient self-reporting of symptoms versus standard of care symptom management, demonstrating a five month improvement in overall survival. These results led many across oncology to believe patient reported outcomes should become the standard of care in cancer care delivery. However, there have been much advancement in technology since that plenary session including strides in remote monitoring and mobile applications. We saw this at the recent ASCO with abstracts on activity trackers and emoji scales. In 2019, we will look to see how these advances can be leveraged to elicit patient reported outcomes while decreasing the collection burden on patients, caregivers, and providers. How will these remote monitoring technologies evolve (e.g. monitoring of heart rate, blood pressure, temperature, PO intake in the home), how will our work force evolve to respond to them, and, further, how can this data be stored and interpreted to improve the risk models discussed above.

  3.  Complex treatment pathways: Anyone who has taken care of oncology patients on active treatment understands that when symptoms develop they often come in clusters. These patients often do not just have abdominal pain in isolation but also nausea, emesis, diarrhea, dehydration, and fatigue/malaise. Organizations and the private market have developed guidelines and pathways for management of these symptoms but they are typically designed to address a symptom in isolation and fail to recognize the complexity of co-occurring symptoms. There is a clinical need for innovative analytic strategies to identify these clusters as well as targeted interventions to address them. In this vein, the National Cancer Institute has called for clinical decision support systems that address co-occurrence. In the current environment of the Medicare Access and CHIP Reauthorization Act and the Oncology Care Model where resource utilization is being closely measured and followed, institutions and practices are compelled to bridge this gap in symptom management. In 2019, we will look to see how treatment pathways evolve to better address the complexity of the oncology patient’s symptom profile to lead to targeted supportive interventions that reduce unplanned acute care.

jop.18.00199f2.jpeg

4. Tele-oncology enabling care everywhere: Tele-oncology is a rapidly developing field that has the potential to be a major disruptive force in oncology. The applications are diverse including triaging and managing symptoms at home, delivering rural care, and remote second opinions. As these visits gain in sophistication over the coming year, these applications will continue to evolve. The old model of having patients come to the institution or practice for visits will hopefully give way to a new patient-focused model where more care is delivered to the patient where they are. We have already seen this in other specialties, and payers, including the federal government, are very slowly evolving policies to provide reimbursement for these telemedicine interventions.

5. Platforms for information sharing: Along with these changes in care delivery, there has also been an increase in the complexity of cancer care with the dissemination of immunotherapy across disease types and with treatment decision increasingly based on a tumor’s molecular profile. The traditional method of sharing information via journal articles has not kept up with the need of physicians to have access to this information in real time at the point of care nor does it facilitate the case-based decision making needed by physicians in the clinic. There is a demand for platforms that allow for this immediacy where oncologists can share information and ask questions of their colleagues. We have seen start-ups enter this space, such as TheMednet, and it will be interesting to see how these business models evolve in 2019 and how journals will respond to them.

In this blog, I will be doing a deeper dive into each of these topics over the coming year. Please respond in the comments below if you think I am missing any big innovation trends in 2019.

With Great Doses Come Great Responsibilities

Oncologists must also protect families of cancer patients who are prescribed pain medications.

By Steve Lee, MD

To great fanfare, health services researchers at the September 2018 ASCO Quality Care Symposium announced that opioid deaths in cancer patients are ten times less likely than in the general population.  As part of a ten-year retrospective study, lead author Fumiko Chino MD of the Duke University School of Medicine reported 0.5 to 0.7 opioid deaths per 100,000 cancer patients, compared to 5 to 9 per 100,000 in the general population.  These findings, the authors argued, supported the continued carving out of cancer patients from increasingly stringent opioid prescribing laws.

These conclusions also nicely supported existing ASCO policy initiatives of reducing barriers to appropriate pain therapy and was the subject of coverage by the ASCO Post as well as an ASCO in Action podcast.

But in limiting concern of misuse of opioid misuse to cancer patients themselves, such avenues of inquiry miss the opportunity to reduce harms to caretakers and friends who gain access to harmful substances through proximity to such high doses. 

Opioid diversion has entered the public conversation, most notably with The Conners, ABC's re-reboot of the 90s classic Roseanne, in which the pilot episode portrays the opioid-related death of the fictional matriarch from a friend's supply. Real-world episodes of opioid diversion from cancer and palliative care patients have also been covered by the press including that of a daughter in Washington appropriating hundreds of opioid pills after her hospice-bound father died .

Unfortunately, rigorous study of opioid diversion is lacking, limiting policy change.  Also lacking is a clear causal narrative linking prescribed pharmaceutical opioids to the illicit substances - chiefly fentanyl - responsible for the alarming increase in American deaths reaching 72,000 in 2017. A popular hypothesis attributes the increase in fentanyl-related deaths to prescription drug control pushing users to illicit alternatives. Is caretaker prescription diversion a gateway to illicit opioids - and deaths?  Further research is needed.

Current state and federal interventions have included biologic testing, prescription drug monitoring programs (PDMPs), opioid prescribing limits, patch return, and drug takeback programs.  Few of these initiatives, however, directly address the diversion question of whether each tablet makes it to the appropriate recipient.

One solution may include directly observed therapy (DOT).  Long the domain of public health departments charged with preventing transmission of tuberculosis, innovative agencies have employed telemedicine to maintain compliance with reduced costs.   In the same way, video DOT (VDOT) is a compelling strategy for opioid tracking; in 2017, the National Institute of Drug Abuse (NIDA) funded emocha Mobile Health, a Baltimore-based VDOT start-up, to track adherence to buprenorphine.

Even if successful in trials, general rollout of interventions such as VDOT for high-dose opioid recipients such as cancer patients would surely be resource-intensive.  Important policy questions would include the party responsible for administering VDOT - physician practices are busy enough as is, pharmacy-based programs would undoubtedly add to already high drug costs, and departments of health would require new funding streams.

Ultimately, further innovation and policy are required to reduce diversion of appropriately prescribed drugs, even from legally privileged oncology and palliative care patients.