Interdisciplinary leadership in cancer care reform Sandra L Wo ng - - PowerPoint PPT Presentation
Interdisciplinary leadership in cancer care reform Sandra L Wo ng , MD MS F ACS F ASCO Pro fe sso r and Chair o f Surg e ry T he Ge ise l Sc ho o l o f Me dic ine at Dartmo uth Se nio r Vic e Pre side nt, Surg ic al Se rvic e L ine I
Sandra L Wo ng , MD MS F ACS F ASCO Pro fe sso r and Chair o f Surg e ry T he Ge ise l Sc ho o l o f Me dic ine at Dartmo uth Se nio r Vic e Pre side nt, Surg ic al Se rvic e L ine I nte rim Vic e Pre side nt, Onc o lo g y Se rvic e L ine Dartmo uth-Hitc hc o c k Me dic al Ce nte r
are uninsured or underinsured
healthcare
continuing to escalate)
Belgium Canada England Germany Netherlands Norway US
Inhospital death
51.2% 52.1% 41.7% 38.3% 29.% 44.7% 22.2%
ICU adm (last 180d
17.5% 15.2% 8.2% 10.2% 40.3%
Outpt chemo (last 180d
33.0% 29.1% 28.2% 18.1% 23.7% 38.7%
Per capital hosp exp (last 180d
$15255 $26480 $9216 $24740 $13137 $15849 $26983
Cancer expenditures by country All cancers, age >65
Bekelman JE et al. JAMA 2016;315:272-283
2010 (2010 billion dollars) 2020 (2010 billion dollars) All sites $124.57 $157.77 Breast 16.50 20.50 Colorectal 14.14 17.41 Lung 12.12 14.73 Prostate 11.85 16.34
Mariotto AB et al. J Natl Cancer Inst 2011;103(2): 117-128.
Projected 27% increase in costs of cancer care in this decade. Assumes current trends of declining incidence and increasing survival.
Cancer services
chemotherapy, RT surgery (inc inpt stay) labs, imaging, hospice,
32% 33% 22% 12%
Mariotto AB et al. J Natl Cancer Inst 2011;103(2): 117-128.
Financial risk moves from payers to providers and the care team
breakthroughs in treatments
Delivery System Integration Payment Integration
“Usual and customary” DRG / PPS (1984) Episode bundled payments Population spending targets with shared savings ACOs Full capitation
Small MD practices, unrelated hospitals Integrated health delivery systems Fee for service Global budgets
Delivery System Integration Payment Integration
“Usual and customary” DRG / PPS (1984) Episode bundled payments Population spending targets with shared savings ACOs Full capitation
Small MD practices, unrelated hospitals Integrated health delivery systems Fee for service Global budgets
Clinical pathways Oncology medical home Episode bundled payments Oncology based ACOs
Delivery System Integration Payment Integration
“Usual and customary” DRG / PPS (1984) Episode bundled payments Population spending targets with shared savings ACOs Full capitation
Small MD practices, unrelated hospitals Integrated health delivery systems FFS Global budgets
Clinical pathways
– Per member per month case management fee – Could include supplemental payments for adherence or achievement of quality benchmarks
Delivery System Integration Payment Integration
“Usual and customary” DRG / PPS (1984) Episode bundled payments Population spending targets with shared savings ACOs Full capitation
Small MD practices, unrelated hospitals Integrated health delivery systems FFS Global budgets
Oncology medical home
– Per member per month case management fee to support care coordination across the care team
Delivery System Integration Payment Integration
“Usual and customary” DRG / PPS (1984) Episode bundled payments Population spending targets with shared savings ACOs Full capitation
Small MD practices, unrelated hospitals Integrated health delivery systems FFS Global budgets
Episode bundled payments
– Complications are costly
Abdelsattar et al. J Oncol Pract 2015
responsibility and accountability for care of a population of patients
– Population‐based spending – Defined array of quality metrics (to discourage skimping on care)
– Pioneer ACOs (more risk, more reward, more hassle) – Medicare Shared Savings Programs
specialties (and thus best opportunities for improvement)
Abdelsattar et al. J Oncol Pract 2015
Abdelsattar et al. J Oncol Pract 2015
Delivery System Integration Payment Integration
“Usual and customary” DRG / PPS (1984) Episode bundled payments Population spending targets with shared savings ACOs Full capitation
Small MD practices, unrelated hospitals Integrated health delivery systems FFS Global budgets
Oncology based ACOs
Source: Crossing the Quality Chasm Institute of Medicine, 2001
– Codman’s “end results” cards (1910’s) – Developed M&M conferences – “Forerunner” of The Joint Commission
– Less resistance – Better data quality – Increasing transparency about the data – Still needs to be led by those of us who provide care
– Solid evidence base supports that the metric leads to an improved
– The measure actually captures whether care was delivered – The process is in the direct causal pathway of the outcome – No unintended consequences as a result of the metric
Chassin et al. N Engl J Med 2010;363:683‐688
– Solid evidence base supports that the metric leads to an improved
– Solid evidence base supports that the metric leads to an improved
– The measure actually captures whether care was delivered
Defined interventions:
– Individual – Group (proctored, peer) – Telephone
– Person‐to‐person contact – eHealth programs
– Nicotine replacement – Other Rx
VS “You should stop smoking”
– Solid evidence base supports that the metric leads to an improved
– The measure actually captures whether care was delivered – The process is in the direct causal pathway of the outcome
Comparison between patient satisfaction and outcomes
Wright et al. JNCI J Natl Cancer Inst 2015;107
– Solid evidence base supports that the metric leads to an improved
– The measure actually captures whether care was delivered – The process is in the direct causal pathway of the outcome – No unintended consequences as a result of the metric
N=1193 patients with stage IV lung or colorectal cancer
chemotherapy treatment
(colorectal cancer) did not understand that treatment was not at all likely to cure
higher scores for physician communication Weeks et al. NEJM 2012;367:1616
– Hawthorne Effect
– Measurement detects variation – Data must be shared and understood – QI tools are needed
Dartmouth-Hitchcock Medical Center Fletcher Allen Health Care Eastern Maine Medical Center Maine Medical Center Catholic Medical Center
1 2 3 4 5 6
1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000
Year Mortality Rate (%)
Clinicians learning from data and each other Data feedback to surgeons
Slide courtesy of J. Birkmeyer
Jha and Epstein. Health Aff 2006;25(3):844‐855
– Common terminology between providers – Classification
Harms et al. Ann Surg Oncol 2016
Clinical Staging– N category cNx, regional lymph nodes cannot be clinically assessed (e.g. previously removed for another reason, body habitus) cN0, no regional lymph node metastasis by clinical or radiological evaluation cN1, clinically detected regional nodal metastasis cN2, in‐transit metastasis without lymph node metastasis cN3, in‐transit metastasis with lymph node metastasis Pathological Staging– N category pNx, regional lymph nodes cannot be assessed (e.g. previously removed for another reason) or not removed for pathological evaluation pN0, no regional lymph node metastasis detected on pathological evaluation pN1a(sn), clinically occult nodal metastasis identified
pN1a, clinically occult regional lymph node metastasis following lymph node dissection pN1b, clinically or radiologically detected regional lymph node metastasis, pathologically confirmed pN2, in‐transit metastasis without lymph node metastasis pN3, in‐transit metastasis with lymph node metastasis
Harms et al. Ann Surg Oncol 2016
– Benchmarking requires standardization of data collection
Taylor et al. J Oncol Pract 2016
communication
– Medical team training “speak up” – Proven increase in patient safety – More nimble with implementation of new programs
– Hierarchy‐ and continuum‐related status differences – Geographic dispersion – Alignment with organizational culture
Adapted from Jain et al. J Oncol Pract 2016
Vogel et al. J Oncol Pract 2016
Thank you
Sandra.L.Wong@hitchcock.org