Stepping into the Unknown

Dawn Holcombe, MBA, FACMPE, ACHE
Editor-in-Chief
President, DGH Consulting, South Windsor, CT

As we enter a new decade, we are seeing a widening gap between those who provide care and those who pay for care. This growing divergence is evidenced, in part, by the different sources being used for clinical pathways and authorized coverage for payment. Initially, payers tend to consider national guidelines, such as the National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology, as a starting point for acceptable treatment choices made by physicians, but then refer to internal policies or external vendors to narrow the parameters required for clinical and payment coverage. The external vendors used for clinical pathways in the managed care world are typically not the same vendors used in the physician community. As a result, payment approvals may be driven by algorithms or preferred treatments that are completely different from those chosen by the treating physician.

Perhaps the answer lies not in the choice of clinical pathway vendors, but in establishing accountability regarding the use of clinical pathways, in the context of a broader conversation between payers and providers.

Pharmacy benefit managers and other external entities try to position themselves as being more capable than physicians of determining appropriate drug utilization. Clinical pathways should be a tool used by providers as a part of total patient management, not a weapon used by external parties to control costs. Middlemen, prior authorization vendors, and such can create a tug of war between payers and providers, often leaving the patient at a disadvantage when it comes to finances, quality of care, and access to treatment.

Is Bigger Necessarily Better?

As a society, are we becoming increasingly burdened with baggage, such as gaps in care, reduced access, and poor quality of care? Could a narrow focus on treatment and drug choices be leading to a growing trend toward increased costs and decreased value in cancer care?

There is a lot of buzz concerning “value-based care” and “performance-based payments,” but where is this leading us? Some employer groups and providers are contracting for carved-out care at distant locales (eg, one-stop shopping through large health systems). Is this really creating better overall care? Isn’t there a negative effect on patients when they are removed from local support systems? Shouldn’t we consider the impact of one-stop shopping at distant locales for multiple cancer treatments on a patient’s quality of life, overall cost profile, productivity, outcomes, and satisfaction?

Where is the disconnect? Perhaps it is in how we define medical care, which may shape our future direction and professional capacities. Are we in a niche specialty? Yes. Do we have obligations beyond our niche? The answer to that question may well determine the future of healthcare.

The Increasing Role of Employers

Employers and regional employer groups are increasing their activity in the healthcare arena to better manage their costs. Cancer care is being targeted by these initiatives, but only with modest success.

When it comes to cancer management, do employers really want one-stop shopping? In many areas, the answer is “no.” In an effort to facilitate effective management of their employees with cancer, employers are beginning to gather in formal and ad hoc groups in metropolitan regions. In fact, in Connecticut alone (a moderately sized state), 3 concurrent employer-driven initiatives are underway.

The largest employer in Connecticut is the state’s government (when you include municipalities and school districts). The state has been rapidly moving on a course to present bundled episodes of care to local providers, with the goal of saving up to 10% in healthcare costs as well as creating tiered provider networks for members. At this point in time, cancer care is not part of the first wave of bundles to be addressed, but it is definitely on the radar.

The Connecticut Business Group on Health (CTBGH) is an employer advocacy group that is exploring alternative contracting and other opportunities for improving care and decreasing costs for its members. Fortunately, this group’s initiatives have developed at a slightly slower pace than those of the Moving to Value Alliance (MTVA), an ad hoc employer-driven group. As a result, the CTBGH may be influenced by aggressive cancer-facing initiatives by the MTVA.

I am fortunate to be part of 2 innovative teams that are building a Network of Excellence (NOE) model with the providers and payers in the MTVA; our initial focus is on breast and prostate cancer. The concept of the NOE is taking our teams into unknown territory—defining standards of engagement and accountability for all parts of the health chain (patients, providers, employers, brokers, payers, and industry). The teams are looking at concepts of predictability, consistency, closing of gaps, communication/collaboration, time­liness, proactivity, and continuous quality improvement. As the NOE teams work through these issues, we are facing challenges head-on that will bring together the diverse parts of the health chain in new ways.

Are We Measuring the Right Things in Prior Models?

Our NOE teams are learning that we need new tools and data. Have we gotten boxed into rigid software that wants to deliver its own version of what data we need while blocking access and data sharing with more flexible, nimble software that may offer essential tools, such as population management; risk acuity and analysis; niche operations and management for patient navigation; care management; compliance and adherence; oral treatments in combination or as standalones; and pharmacy operations management?

What role does each part of the health chain play in prevention, screening, treatment, survival, and end of life? How do we close gaps to improve predictability and timeliness? We cannot afford lack of predictability, consistency, communication/collaboration, timeliness, proactivity, and continuous quality improvement.

How Do We Move Into Unknown Territory?

Healthcare is local, and a new national conversation is likely to start from local successes. One provider cannot build a successful model in a vacuum. Success will come from stepping into the unknown with diverse teams that include the perspectives of patients, employers, brokers, providers, some payers, and even industry. Encouraging open discussion and commitment will create a common ground for designing NOE standards. Moving toward a network approach rather than just considering what can be done within the 4 walls of a practice will allow us to focus on the diverse steps of the medical journey, including screening, diagnostics, treatment, management of comorbidities, and collaboration. This will ultimately lead to the management of patients as whole individuals and as a population, not just as a stand-alone niche for disease.

If you want to move in this positive direction, here are the basic steps to consider. Solutions are not likely to involve one-stop shopping, because closed systems can have their own baggage. There may be alternatives in that market landscape that can weave better, less costly solutions.

  • Break down the silos, recognize what you can do and where you need to include others.
  • Consider employers’ needs and perspectives because these will drive the conversation—not what you as a provider want to see happen. Follow the money. Nothing happens if those paying for care do not see value or justifiability. It is our job to help employers understand how value can be defined and reshaped, but no model will be sustainable or successful if it does not ultimately result in better patient care at lower overall costs to those paying for that care.
  • Seek to increase transparency and interoperability. There are significant technology gaps and barriers that must be overcome. Look to pioneering models, such as the ones being developed in Connecticut, for possible innovative solutions. Through these discussions, clinical pathways become more appropriately part of the provider-patient management responsibility, not to be wielded by payers and others.
  • Work to create better communication across silos between patients, providers, payers, and employers. This will lead to better care at lower costs. Middlemen and layers of bureaucracy and oversight will fall to the side as they are recognized as costly middle layers that are not needed. Healthcare is kept local, and yet global by connectivity. Communication obligations at all levels will break the costly silos.

Together, we can build a better healthcare mousetrap with scalable and replicable alliances. This may be the only way to rise out of the quicksand in which we find ourselves at the start of 2020.

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