Transitioning From Volume to Value in Cancer Care

A Conversation With Thomas A. Gallo, MS

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Thomas A. Gallo, MS

Lee N. Newcomer, MD

[I]t is essential for cancer care providers to successfully bridge the transition from a volume-based care model to one that is value based. The way we currently measure and communicate quality is not comprehensive or well aligned, especially for whom it matters most: our patients.

—Thomas A. Gallo, MS

In an oncology health-care system that is increasingly changing its delivery and payment models, how do busy oncologists successfully bridge the transition from a volume- to value-based, patient-centric model? This, and other topics on value fueled a robust discussion at the Association of Community Cancer Centers (ACCC) second annual Institute for the Future of Oncology forum.

At the ACCC meeting, Thomas A. Gallo, MS, Executive Director of the Richmond-based Virginia Cancer Institute, a large medical oncology community practice, facilitated a conversation among oncology care experts about how programs “communicate quality” in cancer care, especially as we shift from a volume-based to value-based system. The ASCO Post spoke with Mr. Gallo about this rapidly evolving issue.

Defining Value

In order to move from volume to value, we need to come to a consensus about the definition of value. Should that be on a national cancer community level, or can it be defined on an institution-by-institution level?

I think there have to be some common value-of-care criteria that are established at a national level, which are based on consensus-driven standards, particularly when it comes to treatment protocols and practice guidelines. To that end, it’s important to have an impartial organization to help set those tools based on evidence.

However, individual institutions and practices can set quality-care goals for themselves by using national standards as their baseline. And these institution-based practices will generally modify the way they measure value and deliver care to meet the specific needs of the communities and regions they serve.

Whether the care is delivered in a cancer center or a community practice, having the infrastructure in place to collect data is paramount to driving success with the various value-based programs that are emerging. 

Administrative Burden

You made a key point that having the infrastructure in place to collect data is paramount to driving success with the various value-based programs that are emerging. There are, however, current challenges with efficient collection and sharing of information from electronic health records needed for quality assessment and reporting to help oncology staff use the information to improve quality and patient outcomes. 

In the meantime, practices and providers must continue to rely on classic retrospective chart abstraction to assess and report on quality.  While this approach does present an administrative burden for already stressed practices, it is important to stay engaged until more efficient processes are available.  Can you comment on this with regards to transitioning from volume to value?

Well, as a result of all of the external pressures on smaller practices, including administrative costs in time and labor to participate in various quality reporting programs, such as the Physician Quality Reporting System (PQRS), meaningful use, and clinical/quality data registries, we have seen a trend in which smaller practices are merging with larger practices or hospital systems.

Equally important, I think this trend is also driven by the recognition that as we make the inevitable transition from volume-based care to value-based care, providers will need to have the infrastructure in place to gather data and measure value, and larger institutions provide that infrastructure. And I agree with you, that the electronic health record systems will need to improve their capabilities to capture and share data needed for quality and value measurement and reporting.

Lively Roundtable

At the ACCC meeting, you facilitated a forum to garner consensus and progress in measuring and communicating excellence in cancer care. Please share some of the salient points from the forum.

We had a diverse group of about 20 professionals from the cancer community participating in the forum. There were physicians, administrators, pharmacists, social workers, and even a few cancer survivors. Our central purpose was to explore topics that are in the forefront of what’s going on in the cancer community across the nation. Obviously, one of the prime topics is assessing and communicating quality and value in care.

It was a lively roundtable forum, which resulted in a white paper that I hope will be widely received. We all agreed that defining quality in oncology care is challenging, because it’s not like scoring a test or a certification; it’s a process of self-examination and improvement that needs to be integrated into your practice model (see sidebar). And it’s important to imbed quality and value into the culture of your practice by emphasizing improvement, not necessarily punishment—people have to look at every complaint or failure as a learning opportunity used to improve care.

We also discussed how organizations are measuring quality in a number of ways, which was highlighted by an ACCC trend survey in which 110 cancer programs submitted their results. The metrics cited to measure and track quality were largely based on patient satisfaction scores, American College of Surgeons Commission on Cancer standards, ASCO’s Quality Oncology Practice Initiative (QOPI) data, and guidelines by our own program. We looked at quality improvement initiatives that addressed issues such as time of referral to time of appointment, time of appointment to start of treatment, imaging wait times, chemotherapy and radiation therapy during the last weeks of life, and palliative care standards and shared-cost models.

As mentioned, due to the shrinking levels of reimbursement and growing administrative costs, we looked at participation rates in accountable care organizations and found that 24% of respondents are currently involved in an accountable care organization that has an oncology component, which is up from 5% in the previous survey. We also found that 22% of practices plan to participate in an accountable care organization in the future.

Cost-Effective Care

The consensus among the oncology community is that delivering high-value care reduces cost. Did you have a discussion that was centered on cost-effective delivery of care?

We spoke about cost and quality as a uniform measure, in that it has become necessary to intertwine cost and value in the same equation. But one thing we emphasized was that value cannot be a code word for cost reduction. We need to make sure that we are getting the best outcomes for our patients for the money that is spent.

For instance, Lee N. Newcomer, MD, led a 3-year alternative reimbursement pilot program at UnitedHealthcare, with five medical oncology practices covering patients with breast, colon, and lung cancers. They found significant cost savings while improving patient care.

It’s important to note, that in cost and value discussions, the great majority of patients are afraid of bringing the topic of costs into their care. They want the best care possible, and cost is something hard to process when you’re battling cancer. That said, there’s been quite a bit published in the literature over the past several years detailing the financial toxicity of cancer treatment that burdens. We’ve found that many cancer programs offer financial assistance programs to help ease the pressure on their patients. So, evaluating cost-effectiveness in cancer care is based on the perspectives of the patient, payer, and provider.

One thing we all agree on is that in our shifting health-care environment, it is essential for cancer care providers to successfully bridge the transition from a volume-based care model to one that is value based. The way we currently measure and communicate quality is not comprehensive or well aligned, especially for whom it matters most: our patients. ■

Disclosure: Mr. Gallo reported no potential conflicts of interest.


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Consensus Points at the ACCC Institute for the Future of Oncology Forum

Forum participants agreed that:

  • Defining quality in cancer care is challenging.
  • Each stakeholder group—practitioners, payers, patients—has its own definition of quality.
  • Given the growing number of accrediting/quality improvement organizations/standards and reporting requirements, some...