Aine Cryts is a freelancer based in Boston. She is a frequent contributor to Managed Healthcare Executive on topics such as diabetes, oncology, hospital admissions and readmissions, senior patients, and health policy.

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Receiving a cancer diagnosis can be a stressful experience not only for the patient, but their family members. In addition to the shock of receiving the diagnosis, patients may also be concerned about their financial obligations regarding their treatment plan.

That’s why Bensalem, PA-based Alliance Cancer Specialists provides patients and family members with access to a social worker (who is imbedded at one of the oncology group’s 11 practices) to help them navigate through their emotional journey and the financial impacts of oncology treatment, says Ann Marie Edwards, CEO.

This social worker is funded through the group’s participation in CMS’ 

Under this model, physician practices have entered into payment arrangements that include financial and performance accountability for episodes of care surrounding chemotherapy administration to cancer patients. CMS is also partnering with commercial payers in the model.

Another benefit of its involvement in CMS’ oncology care model is the practice has access to data-although “it’s usually about a quarter behind”-on its patients’ total cost of care.

This information allows the oncology group to identify its highest-cost patients and work to curb some of those costs. For example, it can focus more efforts on helping certain patients avoid emergency room visits, she says.

Edwards notes that Alliance Cancer Specialists also receives data feeds from Philadelphia’s HealthShare Exchange, a regional health information exchange (HIE) that links the EHRs of different hospitals and health systems, medical centers, and clinics, in addition to claims data from payers.

These data feeds include real-time updates when one of the oncology group’s patients presents at a regional hospital emergency room, when the patient is discharged, and if the patient is going to a rehabilitation facility.

In the future, Edwards would like this information to flow directly from the regional HIE to the practice’s EHR. For now, her group uses a population health platform from Piscataway Township, NJ-based HealthEC that sends e-mail notifications to Alliance Cancer Specialists when its patients experience a healthcare-related event.

Data about discharge and care transition episodes allows the oncology group to know when its patients return home from the hospital or if they’re going to a rehabilitation facility, which triggers Edwards’ team members to contact patients and get them into the practice for follow-up care.

Edwards has been unsuccessful at getting private payers to work with the group on value-based contracts.

Here are three reasons she says private payers should be interested in partnering with community oncology practices on value-based care contracts:

1. Community oncology settings are lower-cost settings of care

, when compared to cancer centers that are being acquired by hospital networks, where the cost of care will likely increase, she says. That’s particularly the case in Philadelphia, adds Edwards, “where everybody is being bought by hospitals.”

2. More proactive information between community practices and payers will lead to savings.

 “Without sharing data, no one can bend the cost curve in healthcare,” she says. “We can’t just cut costs, we have to manage care. Managing care just means focusing the care on the patients who need it the most. And those patients who are leaking out of the system, who are going out of network … the only way for us to know that is to be exchanging information with payers.”

3. Value-based care can also help retain members.

 “Creativity is required for payers that want to engage in high-cost diseases,” says Edwards. “It’s not by bundling the total cost but by lowering cost while giving patients value that will retain members.”

Articles

CEO of a Pennsylvania-based oncology group shares how participating in a new value-based model is changing the care approach.

New Payment Model Improves Cancer Care at Oncology Group

$6 million. That’s how much a hospital or health system stands to lose each year if it doesn’t figure out how to help physicians who are struggling with burnout, says Kathleen Blake, MD, MPH, vice president of healthcare quality at the American Medical Association. That’s because it will cost approximately $6 million to replace those physicians, she says.

Blake, who discussed physician burnout at the Association of Community Cancer Centers (ACCC) Annual Meeting and Cancer Business Summit in Washington, D.C., in March, says physicians experiencing burnout feel “depersonalized and emotionally exhausted.”

“They’re feeling as though [they’re] not achieving what [they] want professionally, and they have a sense of just not being empowered to do what they went into medicine to do.”

Burnout among oncologists, specifically, is a common problem. A 2014 

 reported that 45% of U.S. oncologists experience it.  

For doctors, the key thing they want to know when they go home is that they took good care of their patients, says Blake. “Oncologists will lose sleep at night and toss and turn.”

Blake says physician burnout isn’t an individual physician problem. Rather, in about 80% of cases, it’s caused by organizational or systems problems.

 by the Rand Corporation which found that the inability to deliver high-quality care is a stressor for physicians. The study, which revealed that physicians find EHRs to be “cumbersome” and contribute to their dissatisfaction, also found that these issues drive physician dissatisfaction.

It’s frustrating for physicians to have to contend with the increased demands for a “greater quantity of care,” since it “detracted from the quality of care in some cases,” according to the Rand study. The lack of interoperability and the amount of time physicians spend on data entry were also cited as stressors for physicians.

Blake highlights providers such as Minneapolis, MN-based Hennepin Healthcare for its work to support physicians. The health system discovered that the way patients are scheduled during the day can have a real impact on physicians’ stress. For example, for younger physicians with children at home, it’s very challenging to have to treat an extremely complex patient at the end of the day, she says.

To remedy this, Hennepin Healthcare has tried to use end-of-the-day scheduling slots for patients who are less complex, which allows physicians to leave the office on time.

She also points to a healthcare provider in the Pacific Northwest that has found a new way to help curb burnout. This provider partners up physicians who are EHR-savvy with physicians who are not. In this case, the physicians who are more adept at documenting within the EHR serve as coaches to other physicians and help them to integrate the EHR more effectively within their work flow.

Staying up to date on the latest medical research is also a challenge that can contribute to burnout, particularly among very dynamic fields such as oncology, says Linda Bosserman, MD, assistant clinical professor and staff physician at Duarte, CA-based City of Hope, who copresented with Blake at the ACCC annual meeting.

That’s one of the reasons she says oncology needs to embrace a team-based approach to care. For example, she highlights the number of times she has to click a button to authorize treatments such as standard chemotherapy. “My team could click that button,” says Bosserman.

Team members who could take the “click burden” off physicians include medical secretaries, medical assistants, licensed practical nurses, registered nurses, and advanced practice clinicians, depending on state laws, she says.

“The unique things that doctors do [are] ensure the diagnosis is correct and determine that the treatment plans are aligned with the wishes and values of their patients,” says Bosserman. “Everybody else can do the other work to document care and make orders, with the doctor signing the orders.”

Healthcare systems stand to lose $6 million if burned out physicians choose to resign or work elsewhere. Here are some ways to curb burnout and its associated costs.

Burnout Hits Oncologists Hard, but Healthcare Systems Can Help

The good news about cancer care is there’s been “tremendous work done to transform how we diagnose and treat cancer patients,” says Barbara Tofani, MSN, RN, administrative director at Flemington, New Jersey’s Hunterdon Regional Cancer Center.

But the bad news, she says, is that patients may have to live with the impact of treatments that “haunt them physically years after we say ‘[they’re] cured.’”

Tofani discussed cancer survivorship at the Association of Community Cancer Centers (ACCC) Annual Meeting and Cancer Business Summit in Washington, DC, in March.

Many patients will continue to live years after their cancer is cured. That’s why cancer survivorship plans, which include a review of the procedures and drugs that were used, in addition to guidance on possible side effects patients may experience as a result of those treatments, are essential to their ongoing care.

Post-cancer care coordination: Ongoing communication 

Patients at Hunterdon Regional Cancer Center receive their cancer survivorship plans in paper format and their oncology provider discusses those plans with them in person. The health system has also created a tab within the EHR to capture information about cancer survivorship. That means the entire oncology care team and the primary care physician know where to look within the EHR to find the information.

This is important for patients as they transition back into the care of their primary care physician. For example, a patient with breast cancer who underwent chemotherapy using Taxol (paclitaxel) may experience peripheral neuropathy, says Tofani.

Peripheral neuropathy can affect a woman’s balance, which can lead to falls. Alternatively, the patient may experience debilitating pain as a result of the condition and then live a sedentary lifestyle, which can lead to weight gain, heart disease, and diabetes, she adds.

With awareness that the patient received Taxol, her physician can pay particularly close attention to peripheral neuropathy as the woman puts years between her recovery from cancer and the rest of her life.

Tofani also highlights the importance of “warm handoffs” between healthcare providers. This is particularly important at a time when providers are dependent on technology, she says. Warm handoffs can be facilitated between oncologists and primary care physicians by care coordinators who are nurses or lay people to make the transition smooth between providers.

Care coordination while fighting the disease: Nurse navigators 

Mark Krasna, MD, corporate medical director of oncology at Wall Township, New Jersey-based Meridian Health System, also discussed care coordination for cancer patients at the ACCC annual meeting.

He emphasizes the role of a nurse navigator who can communicate with all specialists-from the radiation oncologist to the oncologist to the surgeon to the primary care provider-engaged in a patient’s care. While playing a pivotal role as a point of contact for questions from family members, the nurse navigator can also ensure that consensus is reached across all providers in terms of the best approach to care.

Care coordination is attractive to payers because it can lead to fewer unnecessary X-rays and MRIs, says Krasna. Also, involving a care coordinator can lead to fewer hospital admissions related to complications such as dehydration, which many patients experience.

He notes that patient satisfaction is typically over 90% at facilities that provide good care coordination. Those high patient satisfaction scores can also translate to more referrals in the future, adds Krasna. That’s because those satisfied patients will tell friends and family members about their positive experiences.

When caring for cancer patients, improving care coordination in these two areas is key-and it can help reduce healthcare costs.

Improve Care Coordination in Cancer Care: 2 Key Focus Areas

	Reducing hospital readmissions requires just the right mix of clinical expertise and predictive analytics, according to industry experts. Here are two health systems that are hitting their stride.

Atrium Health, formerly Carolinas HealthCare System

	James Hunter, MD, chief medical officer at Atrium Health, formerly Carolinas HealthCare System, says the large healthcare system with hospitals, emergency departments, urgent care centers, and medical practices in North Carolina and South Carolina began its journey to reduce readmissions in 2010. At that time, it focused on providing the best care to patients in the acute-care setting.

About three years into that journey, it became clear that focusing solely on the acute-care setting wasn’t enough. That’s why, in 2013, the health system began using predictive analytics to learn the types of supports patients needed outside the hospital or emergency department.

	Today, its EHR leverages 42 different variables-which include clinical and socioeconomic information-to determine if a patient falls into one of three categories: low, medium, or high risk of readmission.

	Much of this information is captured in patient interviews by case workers. Case workers are able to determine, for example, if patients are able to afford their medications, are experiencing food insecurity, have support from family members at home, and access to transportation for follow-up appointments.

	“More and more, these are the things impacting readmissions-it’s not about whether a doctor put a congestive heart failure patient on a statin,” says Hunter.

	One program that has grown out of Atrium Health's predictive analytics program is its “Heart Success” program. High-risk patients are seen in a multidisciplinary cardiology transition clinic for 30 days by cardiologists with experience treating patients with congestive heart failure, in addition to nurses, social workers, and pharmacists.

	Patients who live within a 45-minute drive to the cardiology transition clinic in Charlotte, NC, receive care in person. Patients further away receive virtual visits facilitated by nurses who come to their homes.

	After being seen at the cardiology transition clinic for 30 days, patients are returned to the care of their primary care physicians, who are briefed on their patients’ status through the EHR, says Hunter.

	At that point, patients have a lot more knowledge about their disease, the signs and symptoms to look for, and people to call if there’s a problem, he adds.

	As a result of this and other programs, Atrium Health has been able to reduce its readmission rate for congestive heart failure patients from 19% to 15%. Hunter notes that this is 10% below the national average of 25%.

	About 960 miles away in Kansas City, KS, David Wild, MD, vice president of lean promotion at the University of Kansas Health System, says the academic medical center was driven to improve its readmission rate when it learned that other hospitals within the Vizient network-of which his facility is a member-were achieving better outcomes. Vizient is a member-driven performance improvement company.

	While the healthcare system’s readmission results were always better than the national average, Wild says the healthy competition led him and his team to seek improvements.

	They decided to use predictive analytics because of their practical knowledge that many patients were being readmitted because of socioeconomic and other factors. For example, often patients lacked certain resources, such as housing and family members who could take care of them after they were released.

	The health system uses a variety of data-from laboratory results to a “random smattering,” such as the day of the week the patient is admitted and insurance plan information.

	One of the “biggest clinical changes” the hospital has made as a result of this analysis is to improve care transitions by providing more detailed discharge information to patients earlier.

	For example, congestive heart failure patients now learn earlier in their hospital stay that having too much fluid in their system is a problem-and that they need to be very careful about the amount of sodium they consume. As patients get closer to discharge, they meet with nurses and a pharmacist to learn that they’ll need to weigh themselves regularly to assess weight gain, which could be a sign that they’re retaining or losing water and indicate that the heart isn’t functioning properly.

	High-risk congestive heart failure patients learn upon discharge that they will have follow-up appointments within three days and another follow-up appointment within seven days, says Wild. These patients receive a phone call from their care team within 24 hours of discharge, and subsequent calls from a nurse or a social worker to transition them to the home environment.

	The team’s use of predictive analytics also showed that patients taking no medications are more likely to be readmitted than those taking many medications. That surprised Wild and his team.

	While they can’t prove it yet, they believe patients who are prescribed and taking a variety of medications may be more aware of their condition and understand more fully why they are taking medications. Patients without medications may not know as much about their conditions and are ripe for education. Wild hopes to validate this theory by testing it in his predictive analytics models.

	As a result of these and other efforts, the University of Kansas Health System has reduced its readmission rate for congestive heart failure patients from 21% to 14%, with isolated incidents when the health system performed better, he says.

Reducing hospital readmissions requires just the right mix of clinical expertise and predictive analytics. Here are two health systems that are hitting their stride. 

How Two Health Systems Use Predictive Analytics to Reduce Readmissions

Lee Schwartzberg, MD, chief of the division of hematology and professor of medicine at the University of Tennessee, is troubled by the amount of variation he’s observed with payers’ approach to reimbursing for CAR T-cell therapy.

“This is transformative therapy, and we really would like to see every payer [realize] the evidence and pay for this type of therapy,” says Schwartzberg, who helped develop a 

 for the Association of Community Cancer Centers on immuno-oncology. “There shouldn’t be as much variation in coverage as we’re seeing.”

And this is despite approval by the FDA of CAR T-cell therapies to treat acute lymphoblastic leukemia and relapsed diffuse large B-cell lymphoma.

Schwartzberg acknowledges that the therapies are expensive. The drugs alone can cost between $350,000 and $500,000-and that doesn’t include the cost of treating patients in hospitals and their follow-up care. Thus, the total price tag can be as high as $1,000,000 per patient.

At that cost, covering all patients who want access to CAR T-cell therapy isn’t sustainable, says Schwartzberg. In light of this, he offers two recommendations to help payers and providers to take ownership of CAR T-cell therapy reimbursement:

Pick the right patients, at the right time, and “just get them covered.”

There are patients, Schwartzberg says, whose only option for a cure is CAR T-cell-and there are a significant proportion of patients treated with CAR T-cell therapies who appear to be cured of their disease or at least have achieved long-term remission status.

 in February that shows patients with leukemia who received CAR T-cell treatment experienced a longer medial overall survival and a lower incidence of toxicity.

Schwartzberg points to reimbursing for the use of stem cell transplants, which were used in concert with high-dose chemotherapy in the treatment of women with breast cancer in the 1990s.

Many payers chose not to cover stem cell treatment for these patients, and that led to lawsuits which some of the payers lost. The result, points out Schwartzberg, is those payers were then required to provide coverage. In this situation, he says, stem cells were being used widely without evidence that they could help cure patients.

By means of contrast, the evidence that CAR T-cell therapy works for a very small subset of patients-namely those with acute lymphoblastic leukemia and relapsed diffuse large B-cell lymphoma, as approved by the FDA-is very strong. Schwartzberg notes that there are thousands of patients with the latter type of cancer, based on current indications.

“These are the last-ditch patients, and everyone believes that CAR T-cells are going to be [used earlier in a patient’s treatment path]. The optimism is that they’ll be used to cure more people,” he says.

One advantage healthcare has today that it didn’t have in the 1990s is the existence of biomarkers that help determine the appropriate patients for CAR T-cell therapy, adds Schwartzberg.

“CAR T is an area where we need careful collaboration between payers and clinicians to come up with guidelines that go beyond what was just in the clinical trials, and to help clinicians pick the best patients for these therapies, if the payers are going to pay for them,” he says. “It’s still pretty early days for immunotherapy and immune-oncology, so not every health plan has the expertise, although I would argue that every health plan should make this an important priority for them because patients are losing out here.” 

Successful CAR T-cell therapy reimbursement begins with careful payer-provider collaboration and taking these two approaches.

Two Ways to Take Charge of CAR T-Cell Therapy Costs

The current recommended treatment plan for many women after receiving chemotherapy and/or surgery for triple-negative breast cancer or ovarian cancer is to wait, says Peter Hoang, president and CEO at Jacksonville, FL-based TapImmune, which develops treatments for ovarian and breast cancers.

Waiting isn’t the approach Hoang wants to take. That’s why he’s enthusiastic about a cancer vaccine under development by TapImmune that could help prevent recurrence of such cancers in women. The treatment is described by the company as boosting the immune system to make the “helper cells in our bodies more powerful.”

In partnership with the Mayo Clinic, Memorial Sloan Kettering Cancer Center, and AstraZeneca, the company has commenced clinical trials to evaluate this cancer vaccine.

 recently interviewed Hoang about the vaccine, which is in a Phase 2 clinical trial. A lightly edited version of this conversation follows.

: What’s the promise of this therapy? Is the goal that it be used in a way similar to the HPV vaccine?

: I think that’s the goal with a lot of cancer vaccines, that they be used as a preventative measure. In some ways, that’s how it’s being used today. The patients who receive this therapy are in remission. What happens after a patient gets ovarian cancer therapy-that’s likely chemotherapy-generally, the patient is put into remission, which means there are very low levels of cancer in the patient. Almost all of those patients will end up relapsing. With ovarian cancer, more than half of those patients will relapse within a year.

While that patient is in remission and is stabilized, that’s when we give them the cancer vaccine. The goal is to drive the immune response to help fight relapse when it occurs and attack the tumor, thereby extending the life of the patient.

There are very clear genetic factors that leave women predisposed to ovarian cancer and triple-negative breast cancer. Obviously, we’d like to offer this treatment for women who are diagnosed with this biomarker-and before they get cancer. That would require much larger clinical trials. It would certainly be fundable once we got the drug approved for use in patients in remission.

: Tell me what the patient experience will look like and what types of patients are appropriate for this treatment in clinical trials.

: After chemotherapy and/or surgery-when the patient is in remission or has stable disease-she comes into the clinic once a month for six months for the cancer vaccine. This is a relatively small injection-not unlike what you get for the flu vaccine.

The vaccine will be rotated over the course of the treatment to different quadrants of the body, much like a physician would inject a flu vaccine into a different part of the body for each subsequent injection, because the body builds up a resistance to the vaccine and because repeated injections in the same area of the body can cause redness at the injection site.

Patients would receive the vaccine under the skin, generally in the arm, buttocks, or the fleshier area of the thigh. After the initial six-month treatment, the patient may come in every two to three months for a booster shot.

It’s very simple and involves almost no side effects. We’ve administered the vaccine to about 150 patients, and the general side effects include a little bit of redness around the injection site, like you might get with the flu vaccine.

: Why are some of the very serious-and very rare-side effects, such as death, associated with immunotherapy not a concern with this treatment?

This is a fundamentally different approach. With blood cancers and the associated toxicity of CAR T therapies, which are gene-modified therapies, you’re taking T cells out of the patient and using a virus to target the cancer cells.

You’re getting that high level of toxicity when the T cells are creating an inflammatory environment once they’re inserted in the patient’s body, which can respond by having a fever. That’s the body’s reaction to a pathogen. That doesn’t happen with our treatment.

With our approach, these aren’t gene-modified T cells. Rather, we’re working with the patient’s body to develop a population of T cells to fight the recurrence of cancer.

Next: When could this be applied to patient care? 

: TapImmune announced in November that it has enrolled the final patient in a company-sponsored randomized Phase 2 clinical study of its novel T-cell vaccine candidate, TPIV200, for treating triple-negative breast cancer. We've also announced that the first patient has been enrolled in a Phase 2 randomized, multi-center, double-blinded, placebo-controlled clinical trial of TapImmune’s novel therapeutic vaccine candidate, TPIV200. This study, which includes 280 patients, is sponsored by the Mayo Clinic, and is fully funded by the U.S. Department of Defense.

[Asked about the general availability of this treatment for patients, a company spokesperson told 

 that “[b]ecause TapImmune is a public company, any commentary on when the drug may be available could be construed as a forward-looking statement. As such, they can’t really answer your question in any capacity other than to show you their pipeline and say that they are doing everything they can to bring the drug to market.’]

: Why should payers and providers pay attention to this treatment approach?

: Today, there are no approved therapies after a first remission with ovarian cancer. All those women can do is wait and those patients will relapse very, very quickly. With access to this treatment, patients will have a much better quality of life. Our treatment extends a patient’s life in a way that doesn’t affect that patient’s ability to enjoy a healthy, fruitful, productive life where the woman can go work, if that’s what the woman chooses to do.

This treatment can take place in a highly economical fashion. While we haven’t figured out the cost yet, it’s certainly less expensive to use our drug than to use something like a PARP [Poly (ADP ribose) inhibitor, which is another targeted therapy to prevent recurrence of ovarian cancer].

[According to the Institute for Clinical and Economic Review, a Boston-based nonprofit that evaluates the value of medical treatments, the monthly cost of a PARP inhibitor for recurrent BRCA-mutated disease can range from $13,679 for olaparib (Lynparza) to $13,940 for rucaparib (Rubraca).]

In partnership with the several big-name cancer centers, one company has commenced clinical trials. Find out how this cancer vaccine would work.