The management of oncology practices has always been complicated. Under the best of circumstances, managing the expectations of patients, staff, and owner-physicians is difficult. If you are lucky, you have been blessed with a strong team and a well-oiled machine. In addition, well-prepared practices have physician leaders and administration who value the strengths that each brings to the guidance and direction of the practice.
The reality is that there are so many elements coming to bear on oncology care delivery that are not under the control of the leadership team. As Ruth Linné Lander comments in her article, “Tension at the Top,” this is where the rubber hits the road—and the road got very bumpy in 2013.
The changes we saw this year are not going to slow. In fact, they are likely to escalate even more quickly over at least the next 5 years as we transition from a predominantly fee-for-service model in-to some form of performance or “value”-based model. Programs in pilot versions now across the country will provide direction, but none of these are likely to emerge as the “one” solution.
Despite the proliferation of “quality” metrics and programs that have emerged in the last 5 years, we see in the article, “Institute of Medicine Recommends Measures to Achieve High-Quality Cancer Care” (page 29) that the Institute of Medicine (IOM) has found that we are in a crisis of quality as a specialty—with little progress to report since the IOM’s last review of cancer quality in 1999. How can this be? Some would blame the lack of financial support; others the fragmentation that continues to plague the healthcare delivery system. Still others would point to lags in technology, or the inconsistency of documentation and its monitoring and tracking. It is undeniably true that each practice or cancer center in the country seems to have built their own platform (even those who use the same vendor as a group down the street). Is it no wonder, then, that the patients with cancer who pay for the care we provide lament the lack of information and definition of “value-based” care?
Dozens of conferences in 2013 addressed quality, value, evidence, and reform in oncology. They were presented from the perspective of the community, the integrated centers, the payers, specialty pharmacies, employers, and leading cancer-based organizations. We are making progress, but clearly we are still all describing different parts of the same elephant, and haven’t yet figured out how to combine these diverse perspectives into a singular vision.
One common issue that has been raised in all of these discussions is the exchange of financial resources—a “cost” or “reimbursement,” depending upon your own perspective. As I move between the payer and provider worlds, I still hear all too often a palpable disconnect between the expectations for what level of financial resources is appropriate, and how those resources will be allocated. How do we reconcile the disconnect between the expectations for better pay for performance, quality, and value, and the concurrent expectations for finding savings in the clearly unsustainable costs for healthcare in the United States?
The simple answer is that we are not going to reconcile those disparate views. There is no more money, and discussions of shared savings are self-limiting at best. At some point, someone (probably the government) is going to announce that “x” amount of dollars will be paid for care, and providers will have to scramble to accommodate that amount.
Good oncology practices, both private and hospital-based, will become meticulous about resource management. We, out of necessity, will turn the delivery models upside down. We are not there yet. Models for reform in 2013 have been more about building the “right” models for solid oncology care. Models that evolve for the future will probably be more focused on “manageable models with limited resources” for oncology care.
It is interesting to contrast the business model of dental practices with medical practices. My sister works for a dental practice in New Hampshire. Even the front desk staff knows the costs of opening the doors each day, the resources necessary to provide each service, and the payment ranges for each service. Schedules are carefully managed so that the mix of services that are brought to each doctor each day helps to keep the practice doors open. Additionally, the doctors and the staff work together as a well-oiled machine to keep the doctors doing only what they are trained to do and get paid to do—putting their hands in a patient’s mouth and providing care. You will rarely see one of the doctors chasing charts, patients, or equipment—or waiting. The staff, working as a team, jumps in and provides full support. We haven’t always managed that operational precision in medical practices, but I predict that we will, out of necessity, very soon.
The IOM report on cancer quality raises some interesting points about patient engagement and what patients should start to expect from a practice. In 2014, we will hopefully look at those expectations and retool our operations so that we can respond to those expectations. That may be the catalyst that gets all of us—payers, providers, government, pharmacy, etc—out of the cycle we have been in during the recent years of pilots, several of which are now discovering that they are unattainable or unsustainable without the continuation of start-up funding (which is an unrealistic expectation). At some point, we will find common ground and a way to make the changes that are needed without new cash infusion and without penalizing the patients who need us. Perhaps retooling with more transparency around the costs and using resources in the most effective manner will get us there faster.
The year 2014 will be a watershed year. Hopefully, the lessons we have learned in 2013 will provide the catalyst. We have good practices, and good care, but we can’t keep practicing as we have. Your leadership will be essential. Have a wonderful holiday season, rest up, and get ready to take charge in 2014.