From the adoption of value-based, consumer-centric care to the arrival of new industry players, such as retailers, change seems constant in the healthcare industry. That’s why it’s more important than ever for organizations to deploy technology wisely to support their business vision and strategy.

The information technology (IT) operation “needs to move from a cost center to more of a value center,” says Subra Sripada, managing director in the healthcare practice at Navigant Consulting. “Simply said, the IT tactical plan needs to align closely with the strategic plan,” he says.

While this is not a new concept, achieving it isn’t easy. So Sripada, former chief information officer and chief transformation officer at Beaumont Health in Southeast Michigan, and other experts share eight recommendations about how to align the work of information technology with the organization’s strategy.  

1. Create a structured governance process

At FHN-a rural health system based in Freeport, Illinois-an information technology governance group composed of C-suite executives meets throughout the year to make sure the IT department’s portfolio of projects supports the organization’s strategy to become a consumer-centric health network. “It really needs to be owned by the IT governance council because the IT department needs the support of senior executives to really get what they need: the resources to get things done,” explains Mark Gridley, president and CEO of FHN, which includes a 100-bed hospital.

Carol Chouinard, vice president of provider technology at Optum Advisory Services, says regular governance meetings provide a venue for C-suite executives to learn about the work of the IT department throughout the year. “Too many CIOs go through this decision-making process, and then they walk away. Then there are these surprises and frustrations the next time they get to the table,” he says.

2. Adopt project management for the entire enterprise

While many healthcare organizations use a project management process within the IT department to vet, manage and track projects, fewer of them have adopted a process that encompasses the entire organization.

But that’s what executives at Albany Medical Center in New York decided to do earlier this year. In March, the academic medical center launched an enterprise program management office. The office coordinates and tracks all initiatives from departments across the organization, such as IT, facilities and clinical service lines, as well as cross-functional projects.  

Projects are completed on a day-to-day perspective at the department level, but the project details from IT and other departments also are fed into the enterprise program management process. “It is completely bi-directional,” says George Hickman, executive vice president, CIO, and chief analytics officer at Albany Medical Center.

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“We can see all the interrelationships.” Hickman continues. “Frankly, it makes the prioritization process transparent and fundamentally clear to all of senior management.” Because many projects compete for the same people and financial resources, centralized project management helps executives balance competing priorities, he notes. 

A team from information technology and finance manages the enterprise program management office. The team reports to a leadership group that oversees Albany Medical Center’s overall strategic plan-an effort the organization calls “Pillars 22,” Hickman says. 

During the annual budget process, CIOs should help other members of the C-suite decide how to deploy technology to fix business problems. They should also provide their peers with insight about the benefits and risks of each option.

As Gridley explains, “For myself as the CEO, I may have a vision for where I think things need to be, but my IT team is the one that needs to help frame the vision.”  

For example, he says, FHN’s executives wanted to provide telehealth services as an alternative to in-office visits for patients. After evaluating the risks and benefits of developing a telehealth program in-house, FHN decided to contract with MDLive, which manages the virtual technology and remote providers but brands the service as an FHN entity. The new service has been live for several months.

“The mature CIOs will always anticipate and be able to manage through changes in the project portfolio. We are in an industry where things change,” Chouinard explains. “The most common is budget pressure and budget priority changes. The second is around M&A activity. The third is leadership changes. New folks come in and they have new priorities.”

For example, he says he worked with a large health system that pulled the plug on a Cerner electronic medical record deployment in one local market because a large, important medical group insisted that the organization’s local hospitals use Epic’s EMR.

Most IT departments need to improve how they manage budgeting, forecasting and spending revisions for the projects in their portfolios, Chouinard says. Even more important, they need to think about IT spending in a strategic way.  He explains the strategic thought process as, “What is the right level of affordability? How much can we do with the money we have?”

Sripada encourages his clients to hold town hall meetings to report back to their staff about the progress the IT department is making to support the organization’s strategic goals. “I’ve always felt that gives a sense of purpose to the IT team,” Sripada says.

Hickman says members of the data analytics team are assigned to Albany Medical Center’s process-improvement projects, so they become familiar with the organization’s corporate strategy through their day-to-day work.

Beyond that, Hickman says he includes an agenda item on Albany Medical Center’s strategy at IT department meetings. He also encourages information-sharing at meetings. “I try to create venues-whether I am there or not-where we go around the table and talk about what we are working on, and the approaches we are taking,” he says.

7. Align the IT project portfolio to the corporate culture.

Organizations have different appetites for the amount of risk they are willing to take on and the rate of change they are comfortable managing. CIOs should fully understand those cultural dynamics before embarking on large initiatives or changing the mix of existing projects, Sripada advises.

“Just because there are technologies available to solve a business problem doesn’t mean the organization is ready to adopt it and benefit from it,” he says.

During his last four years at Beaumont Health, Sripada oversaw the day-to-day activities involved in merging three health systems into one-a process that subjected employees to a rapid pace of change. In hindsight, “we are glad we did it the way we did it,” he says, while also saying that it was a challenging process. “There were a lot of balls that were in the air.”

The IT team needs to keep abreast of new technologies that could help the corporate organization reach its strategic goals, such as third-party apps for consumers. The department also needs to plan for changes to the underlying infrastructure, such as the electronic medical record, to support future IT investments.  

“It is so easy to get lost in the 400 requests that we get, and we have to manage on a regular basis,” Chouinard says. “There is a risk that we will lose sight of what the bigger picture is.”

is an experienced writer and editor specializing in the healthcare industry.

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Ensuring your IT plan is aligned with the organization’s strategy can be critical to success. Here are eight things to keep in mind.

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Cancer is among the most frightening diagnoses for patients to receive.

It is a daunting challenge for oncology treatment specialists, and a persistent challenge for policy makers, payers, and other parties charged with ensuring that high-quality, evidence-based, cost-effective care is delivered consistently for all patients.

In addition to the physical manifestations of oncologic disease and the often very difficult treatment side-effects, many patients experience significant financial distress as a result of their diagnosis and treatment.

Patients are also often left to navigate a complex and unclear labyrinth of healthcare services on their own during a period of intense physical and emotional vulnerability-the disjointed care that is one of the most unfortunate results of the prevailing fee for service payment methodology.

In an attempt to address these issues, many experts are evaluating the potential for adoption of value-based, collaborative care payment models such as Episodes of Care/Bundled Payments as an alternative to fee for service. 

Value-based models are intended to improve patient outcomes and experiences.

They are also intended to reduce the overall cost of care by shifting focus from each unit of care rendered by every independent practitioner, also known as fee for service, to the comprehensive care rendered to each patient, across a full spectrum of providers.

The goal is to use a collaborative, multidisciplinary care model of providers who work to design practice guidelines and evidence-based algorithms that will reduce variation and optimize care, patient experiences and overall costs of care.

Success requires that all stakeholders involved, such as providers, payers and others, communicate and agree to their respective roles in delivering seamless, optimal care. 

Developing value-based reimbursement models to support patients with cancer is significantly more complicated than for other kinds of healthcare episodes or conditions.

Unlike patients who are having surgical procedures which typically are one-time procedures with discrete triggering events, patients with cancer have wide variability in disease state and progression, significant differences in treatment options and outcomes and varying start and end points of treatment.

Despite these complexities, it is possible to design effective models.

Like any other episode of care model, it needs to be structured to clearly define which criteria qualify a patient to be in the episode of care, what services are included in the model and what the start and end points are for the episode.

For example, in the case of a diagnosis of Stage 1 metastatic breast cancer, the episode could begin on the date of diagnosis, first date of treatment or on another point of care. The episode might end at the completion of an agreed upon treatment protocol and appropriate follow-up, usually using an easily administered end point such as one year after diagnosis or other starting point. 

One of the complicating factors in cancer is that stratification of the patient population requires more information than is typically on the claims data held by the payer. Because cancer-even of the same body part-is not a single diagnosis, it requires integrating clinical data with claims data in order to get to the bio-molecular level of disease-the precision required to allow clinicians to make meaningful decisions for patients with cancer.

This requires even more collaboration among clinicians and administrators than in other episodes. 

Collaborative partnerships between providers, payers and other stakeholders engaged in patients’ care are critical to ensure that models are designed to allow clinicians to make the most well-informed decisions based on patients’ specific conditions and genetic and social markers.

It also requires continuous and ongoing review and communication to revise the model as new therapies and treatment options become available.  

, according to the American Cancer Society, and total annual spending on cancer treatment in the United States 

 to exceed $170 billion by 2020, it is critical that we assiduously work to develop models that support patients as they navigate this difficult diagnosis.

In addition, it’s important they receive the precise treatment therapies for their particular disease states and situations using the most cost-effective options for care.

These models are designed to improve outcomes, patient experiences, and manage overall costs of care, and they require commitment, transparency, and collaboration among engaged stakeholders.

Lili Brillstein, an editorial advisor for Managed Healthcare Executive, is a nationally recognized thought leader in the advancement of Episodes of Care as a value-based approach for specialty care. 

She is the CEO of BCollaborative, which works with stakeholders across the healthcare continuum to successfully make the move from fee-for-service to value-based healthcare.

Predictable, seamless oncology care begins with an effective value-based reimbursement model.

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In the study, “Improving Quality and Decreasing Cost by Reducing Readmissions in Patients Undergoing Total Joint Arthroplasty,” conducted by the Nebraska Medical Center, several risk factors have been found to contribute to the complication and readmission rates following total joint arthroplasty (TJA), such as obesity, diabetes, and malnutrition. All of these are risk factors in hip and knee replacement readmission as well.

A. Brion Gardner, MD, an orthopaedic surgeon for The Centers for Advanced Orthopaedics in Bethesda, Maryland, says there are a variety of reasons that an individual with a hip or knee replacement may be readmitted. The most serious cause is experiencing a heart attack shortly after surgery, and some patients with preexisting conditions may be more at risk for this.

“Other grounds for readmission include uncontrolled pain, a wound that has drained or is infected, or a blood clot,” he says. “Patients may also be readmitted if there is suspicion of a blood clot or preliminary infection.”

Brian Hallstrom, MD, is co-director of Michigan Arthroplasty Registry Collaborative Quality Initiative (MARCQI), a Blue Cross Blue Shield of Michigan-sponsored, statewide collaborative of hospitals, orthopaedic surgeons, and medical professionals; and clinical assistant professor of orthopaedic surgery at the University of Michigan. 

“The most common reasons for hip replacement readmission are fracture, dislocation, blood clots, or other medical complications,” he says. “Knee replacement patients are more likely to come in with pain or blood clots. In both cases, the medical returns are often associated with the patients who experience other medical issues, such as diabetes or heart disease.”

Further, constipation is a common problem among post-surgical patients who are placed on opioids, and bowel problems can also be a reason for return to the ED and readmission.

Reimbursement trends for hip and knee replacement

At the Centers for Advanced Orthopaedics, Gardner says it is contracted with Medicare and uses a bundled payment method that has a direct relationship with reimbursement.

“Given that readmissions increase the total cost of care for a 90-day period, this could ultimately impact the organization’s bottom line, depending on what happened and why,” he says. “Also, if the cost of care is too high throughout a set period of time, money may be owed to the government since it then exceeds the target price in the bundled agreement.”

However, when it comes to commercial insurance, readmission is not yet having an impact on reimbursement. Gardner believes in the future, payment may be dependent on performance and quality of care, where reimbursement is withheld for poor outcomes.

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At Blue Cross Blue Shield of Michigan, Tom Leyden, Director II, value partnerships program, said it has developed variable value-based reimbursement (VBR) opportunities for primary care physicians and all specialty types participating in its quality improvement programs.

“For the inaugural program year, we saw 147 orthopaedic surgeons participating in MARCQI receive VBR payments tied to improvements in patients receiving functional assessments and reductions in the percentage of total knee/hip arthroplasty patients sent to ECF/SNFs post-surgery,” he says. “In fact, many of our hospitals are now sending 0% of their patients to SNFs after surgery.”

The second VBR opportunity for orthopaedic surgeons is tied to improvements in overall per member per month medical/surgical cost of care + pharmacy cost; change in cost of care per member per month (PMPM) from the prior year; a single composite score comprised of quality metrics from across many PGIP initiatives; proportion of visits with primary diagnosis of low back pain receiving an imaging study; and adult MRI and CT imaging per 1,000 member years.

“Finally, we have piloted a bundled payment arrangement for non-complicated hip and knee replacement procedures,” Leyden says. “The goal of the pilot program is to address the significant variation in cost and care across hospitals and geographies. We are working with surgeons and healthcare systems to manage the cost and outcome variation of these procedures (including readmissions), and to consider appropriate sites for care.”

Case Studies: Successful Hip and Knee Replacement Readmissions Reduction Programs

Gardner has seen great success in reducing the number of hip and knee replacements that result in readmission by performing surveillance on the patient.

“At my care center, there is a physician assistant who tracks and monitors the patients receiving hip and knee replacements, calling to check in on patients’ progress, comfort with prescribed medications, and physical therapy schedule,” he says. “Using a laptop or smart device, patients also have access to a platform where they can submit any symptoms they are experiencing.”

If any submitted symptoms are red flags, the patient would then receive a phone call. He also encourages patients to call him on his cell at any time of day in order to avoid any unnecessary visits to the ER.

“On the front end, we also do everything possible to ensure that the patient receiving surgery is medically optimized to do so,” Gardner says. “In advance, they must go to their primary care doctor to assess their current cardiac, pulmonary, and renal status, and address any other concerns. This ensures avoidable post-surgery risks are minimized.”

Hallstrom says there are sites participating in MARCQI that have staff dedicated to focusing on pain management. This includes early follow-up phone calls from nurse coordinators.

“The intent of these calls is to catch trouble early, assist the patients, and avoid returns to the hospital,” he says. “Other Michigan sites have focused on reducing opioid-related constipation with education and by providing stool softener kits to patients. When patients receive better care, and have better outcomes, there is less opportunity for complications and a need to return to the hospital.”

Leyden says the MARCQI collaborative has engaged in an ongoing effort to improve the quality of care for all patients undergoing hip and knee replacement in Michigan and these efforts succeed because the surgeons, nurses, data abstractors, quality teams, and other participants work together to achieve meaningful quality improvement goals.

The collaboration allows for efforts to continually be refined, driving further progress, which is evident in the results MARCQI has experienced to-date, including 18% reduction in 30-day readmissions; 17% reduction in ED visits within 30 days (hip); 52% reduction in VTE events; and 88% reduction in infections.

Managing risk factors to drive down hip and knee replacement 30-day readmissions  

The pre-operative evaluation done with the patient’s primary care doctor is essential for identifying and treating any risk factors, Gardner says. With hip and knee replacements, there are well-known perimeters.

“For example, a BMI over 40 increases the risk of blood clots, wound complications, dislocations, and nerve injury,” he says. “In diabetics, a hemoglobin A1C that is above 8 significantly increases the potential risks and must be lowered before proceeding with surgery. In addition, if the absolute levels of protein in the body are not high enough, we would postpone surgery until the lab values are below the threshold for minimizing risk factors.”

Stephen Fealy, MD, leading orthopaedic surgeon at Hospital for Special Surgery in New York, says one of the best ways to manage and mitigate the risk of readmission after orthopaedic surgery is to ensure patients have access to and receive physical therapy as expeditiously as possible.

“When you’re dealing with musculoskeletal injuries and surgeries, the healing process can be complex, long-term, and often requires recurring specialized attention and practice, such as safe incremental exercise to help patients gain back and maintain their strength and range of motion,” he says. “The sooner this can start, the better off the patient will be in both the near- and long-term.”

Hallstrom notes the first, and best step, is optimizing patients prior to surgery. Things like weight loss, smoking cessation, and controlling diabetes before surgery are all ways to help avoid post-operative problems. 

Keith Loria is an award-winning journalist who has been writing for major newspapers and magazines for close to 20 years.

Encouraging weight loss, smoking cessation, and management of diabetes prior to surgery can help avoid post-operative problems.

Readmission Trends for Hip and Knee Replacement 

As such, both payer and provider organizations are looking for creative, sustainable ways to reduce waste and improve the quality of care for patients, especially those who are living with chronic or complex medical conditions. With CMS already collecting data for its first oncology performance measure, 

OP-35: Admissions and Emergency Department Visits for Patients Receiving Outpatient Chemotherapy

, which will affect payments come 2020, many healthcare organizations are taking a long, hard look at where they can prevent, or at least significantly reduce, cancer readmissions.

It’s not a surprise. As noted by the Agency for Healthcare Research and Quality (AHRQ), hospital readmissions, regardless of condition, are remarkably expensive, with collective costs hovering just over $41 billion a year for patients who return to the hospital within 30 days of discharge. But Alok Khorana, MD, a medical oncologist at the Cleveland Clinic, says readmissions are becoming more of a focal issue for cancer care, as more patients are treated in an outpatient setting.

“In the past, cancer patients were generally admitted while they were worked up, staying in the hospital for 10 to 14 days,” he explains. “Today, there is pressure to make hospital stays as brief as possible, which means that many patients are discharged without all of their issues being completely resolved. Since cancer is such a complex condition, with both acute and chronic elements, we often see that readmission rates in the cancer population are higher than those in the general medical population.”

But given cancer’s complexity, what can healthcare stakeholders across the industry do to better prevent cancer readmissions?

Given how little time patients stay in the hospital today, the Cleveland Clinic embarked on a process improvement project to improve outpatient care transitions. Khorana says the project started as a way of looking at “common sense” steps to reduce readmissions. He said their first lesson learned what that a significant portion of cancer readmissions are simply inevitable given this disease’s level of complexity.

“This is important for regulators and for payer organizations to understand,” he says. “In many cases, readmission is the right thing to do for patients. It cannot be avoided no matter what the provider may do.”

Yet, to help reduce the number of readmissions in cases that were preventable, he and his colleagues focused on improving care transitions, providing patients with more support once they were discharged.

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“Cancer patients receive really intensive care while they are in the hospital, from a variety of different clinical staff,” he explains. “The key is to not take all of that away once they went home. We started a program where an oncology nurse checked in with patients within 48 hours of discharge, and then they had a follow-up appointment with the provider within five days of discharge, to help provide continuity of care and answer any questions. We discovered that there were a lot of areas where we could help prevent readmissions just by adding in those extra contacts.”

In fact, by putting this standardized discharge protocol in place, the Cleveland Clinic was able to reduce the readmission rate in medical oncology by approximately 4.5%. 

“It was a modest improvement-but a sustainable one,” he says. “In terms of dollars, we are talking about millions of dollars in savings over the long term. And the patients, of course, have the benefit of not ending up back in the hospital.”

But, given that some cancer readmissions are unavoidable, how might healthcare organizations better predict who is at the highest risk of a readmission?

Carl Schmidt, MD, a surgical oncologist formerly at Ohio State University College of Medicine who is now based at West Virginia University Cancer Institute, hoped to develop a model that could estimate the risk of readmission for individual patients. With such a model in place, oncologists could better determine where to best put care management resources after discharge.

“In our original analysis, we estimated that probably about 1 in 5 readmissions was preventable,” he says. “So, in that 20%, there may be things we can do to stop them from happening. Those patients may just need more interventions. But since some of those interventions are costly, you don’t want to give them to everyone. You want to figure out who really needs them.”

He and a team of colleagues developed a logistic regression model using high-risk factors including abnormal sodium levels, low white blood cell count, solid malignancy, and emergency department visits, among others. When they validated the model, it could reliably predict which patients would go on to be readmitted with about 70% accuracy. He believes future models could use artificial intelligence (AI) tools to improve that percentage.

“Our model was pretty simple, but it still allowed us to flag patients who might need some additional support,” he says. “But healthcare organizations, particularly academic centers with the resources, could come up with a better predictive model using neural networking or other AI methods that offer more precise predictions.”

Justin Bekelman, MD, a radiation oncologist at the University of Pennsylvania’s Perelman School of Medicine who has studied how to be reduce unplanned acute care for patients with cancer, including hospital readmissions, says there is a huge opportunity for healthcare stakeholders to think creatively about how address cancer readmissions. He agrees with Schmidt that predictive analytics will likely play an integral role.

“Today, there are not truly validated predictive analytics that can identify patients who are at the highest risk of readmission,” he says. “But in addition, healthcare organizations can also use those kind of big data approaches to simple find ways to dramatically improve the care of patients with cancer-that will reduce readmissions, too.”

Bekelman, as well as Schmidt and Khorana, all argue that addressing this issue isn’t something that healthcare organizations can do alone. There is a role for payers, too-either by funding larger scale research efforts or by providing predictive models and tools for their provider partners to use to improve care for this patient population. Jessica Saba, PharmD, director of Value Based and Population Health at Highmark, Inc., a large Blue Cross Blue Shield plan serving Pennsylvania, West Virginia, and Delaware, says it’s certainly something that health plans like hers are actively working on.

“Cancer care, traditionally, represents quite a large bit of healthcare spend-and there are many direct and indirect ways to try to manage that,” she says. “And, certainly, analytics is an emerging area for Highmark and we are looking at ways that data can help. We are working quite hard to provide more tools and insights to our physician partners so they can more effectively manage these cases.”

For his part, Schmidt says he is buoyed by the amount of academic research being done on this issue. And he hopes that healthcare organizations, both of the provider and payer variety, are not only paying close attention to the studies-but looking for ways that they can get involved to help.

“This is about a lot more than just readmission numbers,” he says. “Trying to reduce them in payer contracts or with quality metrics that say something like, ‘Oh, you need to drop your readmission rate from 14% to 13.2%,’ isn’t going to work. Healthcare stakeholders need to collaborate and come up with better, smarter models so we can understand and undertake evidence-based measures that will provide the best quality care for our patients-and, with that, reduce readmissions along the way.”

Kayt Sukel is a science and health writer based outside Houston.

As more healthcare organizations look to curb hospital readmission rates, they are taking a hard look at one of medicine’s most complex conditions-cancer.

Strategies to Help Reduce Hospital Readmissions for Cancer

Cancer-related pain doesn’t always stop when active treatment ends. Patients with stabilized disease or in remission are living longer due to earlier detection and better treatments. Managing chronic pain (six months or longer) is increasingly important. About 

5% of the U.S. population are cancer survivors, 15.5 million people

, according to “Pain in Cancer Survivors: How to Manage,” June 2019, 

. Cancer-related pain can be from the disease itself, or due to treatment. Most cancer patients will experience pain at some point during their illness, says Jacob Strand, MD, chair of palliative care medicine at the Mayo Clinic in Rochester, Minnesota. About 80% to 90% of those with metastases, who are incurable, will have cancer-related pain, Strand says, as will up to 

Ideally, treating pain involves a multi-prong approach. That might mean some combination of physical therapy, behavioral therapy, blocks/injections, and medication. Not all health insurance covers an extensive approach, though undertreating pain impacts a patient’s health and quality of life substantially. As patients live longer after active treatment, oncologists see the patients less, leaving pain management in the hands of primary care physicians (PCP), who may not feel equipped to treat it.

A typical assessment for pain management includes pain assessment, functional assessment, and then risk assessment, says Judith Paice, PhD, RN, director of the Cancer Pain Program in the Hematology-Oncology division at Northwestern University in Chicago.

The risk assessment is newer and still not performed by most oncologists, Paice says. It includes questions about smoking, alcohol use, and prescription substance use not as prescribed. It also includes a family history of substance abuse to give a “crude understanding of genetic risk” and to understand what substance issues might exist in the home. She takes all the answers into account, while trying to determine if their pain is likely to respond to opioids, and if they’re at risk for abuse.

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A cancer patient can suffer from various types of pain. Tumor-related pain can be from a tissue injury, like a mass effect from the tumor pressing against the bone or nerves. Pain can be treatment-related, like pain after surgery, or associated with radiation therapy. As radiation gets more precise, patients are experiencing less pain. “Unfortunately, pain associated with chemotherapy is increasing, as more and more agents are causing peripheral neuropathy,” Paice says. Steroid use can cause avascular necrosis and bone fragility. Aromatase inhibitors and hormonal therapies for prostate and breast cancers can cause pain. “If one in eight women with breast cancer are estrogen positive, they’re likely on aromatase inhibitors for five to 10 years,” Paice says. Stem cell transplant can lead to graft versus host disease. With new treatments always arising, pain management is a moving target, she says.

Assessing and treating function, not pain severity

Pain used to be assessed and treated based on intensity scores, with patients rating their pain on a 0-10 scale, and trying to lower the pain to a different number. That is changing. Clinicians are now focused on functionality, what the patient can do after pain management that they couldn’t do before it. Clinicians ask patients about their physical and emotional goals, understanding what improved function and quality of life looks like.

Improved functionality could be performing activities of daily living that they can’t do because of pain, Strand says. “That shift is particularly important in chronic cancer-related pain, where there’s no cure for the underlying problem,” he says.

Multimodal therapy is the preferred approach. While medications work well for some, a medication may be contraindicated due to a patient’s other medical issues. And not all pain can be addressed with pharmacological treatments. Treatments like physical and occupational therapy, and cognitive behavioral therapy (CBT) are often helpful, though CBT sometimes carries a stigma. “I try to reframe it,” Paice says. She tells patients “our psychologist here is not for crazy people. It’s for normal people going through crazy times.” She tells them they are going through a difficult time, but have an inner strength that the therapist will help them find.

The idea behind using multiple interventions is to provide the best outcomes with the fewest side effects and least risk. Not all therapy types are indicated for each patient, but it’s important to consider different treatment modes. In the best scenario, patients have access to various therapies to help them move appropriately and with emotions. “It’s really tough to get all of that paid,” Paice says.

Five years out from cancer treatment, many patients are no longer seeing their oncologist more than once annually, if at all. Some academic medical centers develop care plans for PCPs to follow, but they mostly recommend screening practices, not pain management. That can leave PCPs in the uncomfortable position of treating cancer-related pain, without the knowledge.

“Clinicians have historically not been well trained to manage cancer pain at all stages of their diagnosis, illness, survivorship, and end of life,” Strand says. With a significant patient population with growing health needs, it’s important for all physicians and advanced practice providers to get pain management training.

Palliative care clinicians tend to see more difficult cases, Strand says, either those with a complicated medication regimen, or patients with coexisting symptoms like mood disorders, or patients with a high risk of relapse.

One concern that cancer patients have is the fear of cancer recurrence. A new pain complaint is stressful to patients, given the uncertainty of the disease returning. A clinician treating a cancer survivor for pain should be aware of that.

Clinicians try to optimize use of non-opioid medications for chronic pain, Paice says. That can include nonsteroidal anti-inflammatory drugs. Steroid injections and nerve blocks are useful, especially for abdominal pain related to pancreatic cancer, says David Craig, PharmD, clinical pharmacist in pain management/palliative care at H. Lee Moffit Cancer Center in Tampa, Florida. “Drugs are not very good at managing abdominal or neuropathic pain,” he says.

But 30% to 50% of those getting antineoplastic therapy, and 75% to 90% 

of those with advanced disease, have pain best treated by opioids, according to UpToDate, topic updated June 2019. Opioids have received a lot of negative press lately. “Our first goal as physicians is to do no harm,” Strand says. And that means being thoughtful about how medications are used and how patients are monitored, to minimize even unintentional harm.

Not only are some clinicians reticent to prescribe opioids when indicated, but patients are afraid to take them. “We need to be really direct and ask them if they’re worried about becoming addicted,” Paice says. Patients may not take prescribed opioids out of fear, or because they receive negative messages from family members. That contributes to undertreatment of pain.

Part of Strand’s risk screening process includes checking the state prescription monitoring database, to see if the patient may be at risk for substance abuse. Closely monitoring outcomes and patient function, as opposed to pain level, helps with safer prescribing. “We can provide it safely and still manage pain effectively,” Strand says. He tells patients that part of his job is to make sure they’re safe, and that can help overcome some fear of addiction. The number of patients in his practice who benefit from opioid treatment far outweigh the number of patients harmed from it, he says. Monitoring patients with opioid prescriptions is labor intensive, requiring close communication with oncology and PCP colleagues. “Opioids for all” is not an appropriate strategy, but they’re helpful for some patients.

Clinicians disagree about the utility of cannabis in pain management. Craig does not recommend it to his patients, as he says there’s not enough data to support it, and patients think they can buy it from someone off the street, smoke it, and it will work. “We don’t disallow it, but we don’t recommend it,” he says.

, “Medical Oncologists’ Beliefs, Practices, and Knowledge Regarding Marijuana Used Therapeutically: A Nationally Representative Survey Study,” in the Journal of Clinical Oncology reported that up to 80% of oncologists have discussed medical cannabis use with patients, though only 30% felt informed enough to recommend it. The study, which surveyed 400 medical oncologists in 2016, showed that 67% of oncologists thought it was a helpful addition to standard pain management options. 

 noted that some studies found that inhaled marijuana was helpful for neuropathic pain, and that those using marijuana extracts in clinical trials needed less pain medication.

Strand has comprehensive discussions with his patients about medical cannabis, as he knows patients will ask about it. He says the data on effectiveness in pain management for cancer pain is mixed. In his practice he’s seen patients benefit from it, and those who don’t. Like many treatments, clinicians need to determine how cannabis fits into treatment, and monitor it closely for side effects. “They’re not the savior to our problems with pain, but they should also not be discarded,” he says. Before a patient uses cannabis for pain management, he asks them to track it in a pain diary, just as they would with any other pain medication.

Undertreating pain is a problem, as is overtreatment. Pain management allows a person to be functional. “They need to move to prevent lung complications, blood clots, and improve their general quality of life,” Paice says. “We don’t want people isolated in their homes because the pain is too bad to move.” This happens due to access to care, as well as for those afraid to use opioids.

Undertreatment can also affect survival. “Sometimes symptoms that are poorly controlled can lead patients to discontinue therapy,” Strand says. He tells patients that if their pain is preventing them from getting out of their chair, they’ll have a worse outcome than if they were functional individuals.

Deborah Abrams Kaplan covers medical and practice management topics. 

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The race to decrease drug costs is heating up across America. The Trump Administration has one idea, House Majority Leader Nancy Pelosi has her solution and Big Pharma has prosed a resolution to the problem. But some insurers are now rising to the occasion and finding ways for members to afford expensive specialty drug treatments, such as gene therapy.

The cost of gene therapies is expected to reach 

 in the United States by 2024. While only two therapies have yet to be approved, they are indicative of the high price tag.

Luxturna (voretigene neparvovec-rzyl), the first FDA-approved prescription gene therapy for people with inherited retinal disease leading to blindness, costs $415,000 per eye. Zolgensma (onasemnogene abeparvovec-xioi) for children under two years old with spinal muscular atrophy is set at $2.1 million.

These potentially life-saving medications would undoubtedly break the bank and prevent coverage and access by patients.

Cigna has developed a coverage program, Embarc Benefit Protection, for the two therapies that don’t require any out-of-pocket payments related to the cost of the medicine. It is expected to go live by January 2020.

Payers pay a per-member per-month (PMPM) fee to access Embarc’s gene therapy network. Physicians are required to submit prior authorization requests for patient eligibility. Steve Miller, MD, chief medical clinical officer for Cigna, hopes that PMPM will reach $1.

Miller says that Cigna chose gene therapy because of the integral part it will play in overall healthcare. He also is concerned by the history of gene therapies, two of which were approved in Europe and have since been taken off the market because they are cost prohibitive.

“Without patient access, a product can become a tremendous market failure,” Miller says. “Some plans are writing policies to exclude gene therapy, while stop-loss insurers are capping their exposure. Although gene therapy is not yet urgent or presenting any threat, we want to capture the market before insurers decide to exclude these treatments from their benefits.”

He wants to eliminate all barriers to joining the Embarc coalition of subsidiaries and affiliates so that patients are not forced into government insurance. The program initially will target Cigna members followed by Express Scripts’ book of business, then EviCor and finally non-affiliated health plans. 

Brian Duffant, vice president at BluePath Solutions, a market access and health economics/outcomes research consulting firm based in Los Angeles, says payers are developing new payment programs to address the projected future increase in demand for gene therapies based on the burgeoning gene therapy pipeline.

The addressable market for gene therapies could grow as large as 2.4 billion patients worldwide, according to Guggenheim Securities.

Miller says Embarc will combine Cigna’s innovative payment with the health services, medical benefit management, and specialty pharmacy expertise of Express Scripts, a pharmacy benefits manager; eviCore, a healthcare management company; Accredo specialty pharmacy; and Curascript SD, a specialty pharmaceutical dispensing and distribution company.

AveXis, a subsidiary of Novartis Corp. that developed Zolgensma, also is partnering with Cigna’s coalition members offering payers pay-over-time options up to five years and outcomes-based agreements up to five years for the drug. In the same vein, the Cigna partnership will envelop Spark Therapeutics, the producer of Luxturna.

Increasing Access to Gene Therapies Requires Innovative Payment Approaches

“There wasn’t a paradigm in the private sector for this kind of coverage, but we wanted to get something out there,” Miller says.

Cigna chose an approach that considers the impact Embarc will have on all stakeholders, including manufacturers, providers, payers, and patients.

Limits on barriers to access, eliminating the need for copayments

Patient encouragement to make the best choice without financial support playing a role

Cigna anticipates providing best prices and value-based pricing, keeping the price of Zolgensma for example, within the range of traditional cost-effectiveness thresholds used by the Institute for Clinical and Economic Review (ICER)-not just what the market will bear, Miller says. ICER produces cost-effectiveness analyses.

For payers-employers, insurers, and unions-Embarc expects to provide low prices with pass-through and transparency; spread overhead among as many patients as possible; use uniform utilization management criteria so there is no adverse selection, which gives payers 100% predictability; and establish a flat PMPM not based on usage.

Cigna will enable payers to use Embarc as a white label, payment product to build Cigna’s coalition, Miller says.

Patients should receive speedy treatment without any copayments, while providers are expected to be part of centers of excellence to keep costs down.

Miller says patients will pay little-perhaps an administrative fee-to nothing for the new available gene therapies. By negotiating best prices with manufacturers, he anticipates it will be possible to buy down copayments.

“What is clear is that payers will likely use a combined approach to manage gene therapy utilization, including use of centers of excellence; population risk-pooling; and short- and long-term, outcomes- based contracts with manufacturers, reinsurance, and programs intended to pay for gene therapy over time as opposed to one up-front payment,” Duffant explains.

 developed by the PwC Health Research Institute (HRI) outlines a menu of contracting and price-assistance models that could make gene therapy more accessible and affordable.

HRI, however, found in a survey that just 56% of pharmaceutical executives reported using at least one value-based drug contract, while only 14% of payers said they engaged in outcomes-based agreements with biopharmaceutical companies.

Cigna is working on version two of Embarc that will target patients most likely to benefit from gene therapy to limit adverse risk. “The product will begin to look more traditional as more patients are involved and prices decrease,” Miller says.

Duffant is concerned that if a small employer has even one patient who needs gene therapy, this could have a catastrophic impact on employers’ overall healthcare spend. “Payers need a way to manage a new paradigm of gene therapies with a high one-time upfront cost and uncertain clinical benefits over the long-term,” he says.

“While some of the populations eligible for gene therapies may be relatively small compared to other therapeutic areas, gene therapies generally address clear areas of unmet medical need and have short-term data as proof of evidence in select patient populations,” Duffant says. “The key question is whether gene therapies can deliver the promise of long-term health benefits for patients, and we are simply too early in the game to see if this will be true.”

Steve Wojcik, vice president, public policy, National Business Group on Health, believes that programs like Embarc sound like an installment finance option versus a one-time expense to cover gene therapies. “They should provide more predictability for employers and can spread payment over a period of time,” he says.

He recommends using clinical management tools to target the right persons with the right therapies.

Although it is a new way of financing specialty pharmacy and gene therapy, it doesn't get to the challenge posed by these expensive drugs; it doesn't address long-term sustainability and is out of line with economic and wage growth,” Wojcik says. “It is similar to covering college expenses while not addressing inflation.”

He concedes that patients are shielded from cost sharing, but acknowledges an underlying payment exists. He is concerned that smaller employers are apt to face higher premiums to offset the pricing arrangement. “There are already limits on OOP payments,” Wojcik says.

While he doesn’t expect a big impact initially with these payment programs, he believes that as more gene therapies hit the marketplace and affect a wider population, the result could have more significance and provide affordable healthcare.

Other insurers to jump on coverage bandwagon

Ethan Slavin, spokesperson for Aetna, says the insurer is working hard to effectively manage the cost of these therapies for its clients and members. For example, Aetna is currently developing:

Refined pharmacy benefit management strategies, including formulary and utilization management programs, for therapy classes with high-cost entrants that have available alternatives.

Stop-loss products for clients looking to better control medical costs, including an innovative reinsurance instrument specifically designed for gene therapies.

Alternative payment models, including annuity payments that spread the cost of ultra-high cost drugs over a period of time, and may provide some clients with options to control spending in a single year.

The heath plan also is exploring outcomes-based contracts with manufacturers to ensure patients and customers derive clinical benefit and value from gene therapy products. In addition, Aetna is advancing a network strategy that ensures patients receive treatment at high-value sites of care in terms of both clinical quality and cost.

 published by the Advisory Board, Anthem has a product under consideration that includes reimbursement or stop-loss options that would protect employers from the negative financial repercussions of gene therapies.

Payers are finding ways for members to afford expensive specialty drug treatments.

Accessibility and Affordability of Gene Therapy

Cincinnati Children’s Hospital Medical Center

 has called Avondale, Ohio, home since 1926. The hospital has been on a decades-long mission to lead, advocate, and collaborate in order to improve the health of local children and reduce health disparities in targeted populations.

Two such population groups were the focus of a health initiative aimed at reducing the inpatient bed-day rate by at least 10% by mid-2020 for children from two nearby neighborhoods, and to narrow the gap between those neighborhoods and healthier ones.

“This was not a simple or straightforward program,” says the initiative’s lead researcher Andrew F. Beck, MD, attending physician, Division of General & Community Pediatrics and Division of Hospital Medicine at the health system. “Rather, it was complex, involving active collaboration with community partners.”

Beck and fellow researchers explored common elements that underpin morbidity across conditions and serve as key contributors to hospital days and disparities. This focus allowed them to bring the right hospital resources and community partners to the table to tackle the most problematic conditions.

The multi-level approach involved analyzing real-time EHRs to identify neighborhood “hot spots” in need of additional support for children living within those neighborhoods; optimizing chronic disease management by closing care gaps during hospitalizations and after discharge; mitigating social risks such as housing instability and limited access to medications and personal hygiene supplies; and helping children transition out of the hospital. The researchers hoped to develop, test, and refine a theory for how to narrow equity gaps across broader geographic areas.

There were exact improvements within each of these domains.  First, we engineered the EHR to send us alerts every morning if any child from the target neighborhoods was admitted.  This prompted a multi-disciplinary huddle for learning purposes to explore what could have prevented, care gap closure to look into preventive solutions during the hospitalization, like immunizations, and consideration of transition needs (e.g., follow up appointments, medications).  Second, we placed focus on common chronic conditions that were disproportionately contributing to bed-days.  For instance, we have pursued work with our asthma patients to ensure that they have controller medications prior to exacerbation seasons.  We also looked at the distribution of RN and social work care managers to ensure that they were connected with our most at-risk patients.  Third, we have worked with community partners to assess for patterns in social risks.  For instance, we have actively sought to identify building complexes that need broader advocacy and not just patient-level work.  When we identified resource limitations, we actively worked with the local food bank to start an in-clinic food pantry to deliver food into the neighborhood and bolster access to hygiene supplies.

How one hospital is combatting neighborhood-specific problems.

MHE November 2019

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