1. Eastman, Peggy

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The National Comprehensive Cancer Network (NCCN) gave a preliminary glimpse of new findings and recommendations on cancer care at a policy summit held at the National Press Club in Washington, D.C. The recommendations are being developed by a multi-stakeholder working group NCCN convened to address the realities and opportunities of changing paradigms in cancer care delivery.

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The final recommendations will be published in the Journal of the National Comprehensive Cancer Network in early 2019, NCCN CEO Robert W. Carlson, MD, told Oncology Times. He said that the policy initiative is needed because currently some of the new payment models from changing paradigms are proving "challenging" for oncologists.


Carlson also noted that some of the proposed changes in Medicare reimbursement for documentation of evaluation and management services issued by the Centers for Medicare & Medicaid Services (CMS) could have negative impacts on patients' access to care, especially patients with complex illnesses such as cancer.


The policy recommendations will fall into four major categories, said Katy Winckworth-Prejsnar, MPH, an NCCN Policy/Advocacy Fellow.


1. Delivery of innovative treatments such as precision medicine, CAR T-cell therapy, immunotherapy, and next-generation sequencing


2. Team-based coordination of cancer care and the scope of practice


3. Delivery of care under value-based payment models such as the Oncology Care Model (OCM)


4. Shortages and diversity in the cancer care workforce



At the policy summit, the proposed NCCN recommendations were presented by the working group co-chairs, Leonidas C. Platanias, MD, PhD, Director of the Robert H. Lurie Comprehensive Cancer Center at Northwestern University, and Warren Smedley, MSHA, MSHQS, Director of the Service Line for Cancer at the University of Alabama at Birmingham Health System and an NCCN Board Member. "This is a very complex system that we exist in," said Smedley. "There's no one easy solution."


Preliminary Recommendations

Some of the working group's preliminary policy recommendations include the following ideas:


* Outline policies to protect patients' access to high-cost and high-impact therapies that include value-based payment mechanisms to reimburse costs outside bundle payments; modernization of reimbursement systems, especially in CMS, to accommodate novel therapies and advanced diagnostic tools; tasking of professional societies such as NCCN to develop tools, standards, and evidence-based guidance for the delivery of innovative therapies, including standards around the scalability of such efforts if they are safe and appropriate; development of dissemination methods for the delivery of novel therapies, as well as strategies to measure the quality of these novel therapies in the community; promote professional training for use of these therapies; establish a framework or guidance document for evaluating the clinical utility of emerging precision medicine biomarkers and clinical indications


* Expand beyond the OCM to implement other models that are considered best practices in the field to promote high-quality cancer care


* Protect patient access to high-cost innovation and the most appropriate care within value-based frameworks via a mechanism to reimburse these high-cost innovations under the umbrella of value-based payment models


* Develop team-based models to support all members of the care team, including but not limited to oncologists, advanced practitioners, community health workers, patient navigators, community health workers, pharmacists, genetic counselors, dieticians, and nursing educators


* Establish reimbursement and coding mechanisms to support team-based models of cancer care


* Support greater electronic health record interoperability through rule-making


* Support greater transparency through the availability and exchange of claims data from CMS and private payors to providers, while also focusing on greater clarity through guidance documents regarding regulatory hurdles (such as privacy laws) that might prevent this sharing


* Develop standardized metrics and a shared definition of value in collaboration with providers and patients


* Establish an inter-state partnership for licensing recognition of practitioners, building on the Interstate Medical Licensure Compact model


* Address workforce shortages through expanded telemedicine policies and regulations


* Establish loan forgiveness programs for practitioners working and mentoring in underserved areas, using other professions, such as education, as possible models.



A Team Approach

Carlson stressed the importance of the team concept in high-quality cancer care delivery. "The oncologist can't do everything," he said. "Oncology care is a team sport today."


Keynote speaker Amy B. Porter-Tacoronte, MBA, Chief Administrative Officer for the Cancer Service Line at Johns Hopkins Health System, agreed. A member of NCCN's Board of Directors, she described how the patient-centered, transdisciplinary, coordinated cancer care team works at Hopkins. "We were getting signals that things were falling through the cracks," she said of the impetus for the new model.


In this new model, she noted, the emphasis changes from what an individual practitioner can do for the patient to "how can I help my team do better?" The shift in emphasis is meant to cut down on medical errors, unnecessary or repetitive diagnostic tests, unnecessary emergency department visits, and preventable hospital admissions and readmissions. Care coordination is "a necessary first step to allocating resources to an efficient system," she noted.


Under this new team model, she said, "Navigation is part of everyone's responsibility" to ensure that the cancer patient has the best experience possible. "Navigation is something that we all do every day."


Porter-Tacoronte described how huddles and team meetings help the team function as a coordinated whole. "If we're working in a team, sometimes we're going to need help," she noted. Screens help with care planning and raise red flags, such as distress and substance abuse. A patient access line provides one number for the patient to call, there is an after-care clinic, and "buddy" guides go home with patients to help them make the transition from hospital to home. "I can't tell you how many compliments we get on this program," she said.


Porter-Tacoronte noted that the coordinated care team model requires a staffing commitment to a culture of care coordination, access to health providers post-discharge, and patient engagement in order to honor the patient's values and beliefs. Under the new coordinated team model she described, "the provider handoffs are still a challenge," she noted. But ultimately, she said, coordinated team care results in better care and more cost-effective care. "It's an evolution that's going to stay."


Information technology director and patient advocate Yelak Biru, who was diagnosed at age 25 with stage III myeloma in the mid-90s, stressed that cancer patients themselves have a responsibility for coordination of the cancer care team so that it works smoothly. For example, he said, a patient should take responsibility for making sure a scan is received in a given institution, the right institution.


Biru, who is active with the International Myeloma Foundation and the Global Myeloma Action Network, among other groups, noted that he has a primary oncologist who is his principal coordinator of care, a primary oncology specialist, and a primary internist. He noted that many cancer patients have co-morbidities, and thus other specialists, such as cardiologists, may have to be called in. So, according to Biru, it is vitally important that cancer patients participate actively with members of their care team.


Challenges, Considerations

Ray Page, DO, PhD, FACOI, President and Director of Research at the Center for Cancer and Blood Disorders in Fort Worth, Texas, described the challenge of adopting new cancer care delivery changes at his center. "Practice transformation was huge, and it was difficult," he said. But it was valuable, he added. The practice transformation involved triage pathways, expansion of clinic hours to evenings and weekends, use of treatment pathways, centralizing phone banks, and standardizing clinic processes. When he interviews and hires physicians, Page tells them, "If you are not willing to adapt and change, this is not the place for you. This is the wave of the future. If you can't change, you will be paid less."


Invited speakers and panelists at the policy summit noted that changing paradigms in cancer care delivery can be especially hard on certain groups of providers. "The challenge in a lot of this is the infrastructure of the new models of care," said Robert S. Saunders, PhD, Research Director for Payment and Delivery Reform at the Duke-Margolis Center for Health Policy in Durham, N.C. "It's hard for oncology practices to make that investment upfront."


Indeed the OCM is "a lot more work than providers and CMS had anticipated," said Christian G. Downs, MHA, JD, Executive Director of the Association of Community Cancer Centers, agreeing with Saunders. He is concerned about small oncology practices (two or three physicians) who lack the infrastructure to function easily within the OCM. Downs suggested looking at where the OCM isn't working: "What do we need to do to make it work?" he asked.


Downs also suggested looking at value in cancer care broadly: surgery, radiation, chemotherapy, and support services. "What's going to happen to that patient in their total cancer experience-who you're treating, where you're treating, and how you're treating? I look at it as the whole community."


"I think the OCM has had a sentinel effect," said Lee N. Newcomer, MD, MHA, of Lee Newcomer Consulting.


"I want to give the OCM credit," added Newcomer, who spent the majority of his career with UnitedHealth Group. But, he noted, "the extra care in Medicare is really unfunded. It's very clear that Medicare isn't paying what it really costs to take care of cancer patients."