Introduction to the Cancer Care Continuum – Executive Administrator
According to the National Institutes for Health, the cancer control continuum is a phrase used to describe the various stages cancer can play in a person’s life, including prevention, early detection, diagnosis, treatment, survivorship, and end of life. It’s critical to understand the interdisciplinary actions among patients, health care providers and payors to provide patients with accessible, affordable care and healthy lives.
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Per the World Health Organizations' (WHO's) International Agency for Research on Cancer, Globoscan 2018, there were over 7.6 trillion people living with cancer and 17 million new cancer cases diagnosed in 2018. The largest percentages of people with all cancers (except non-melanoma skin cancers), 50.9%, are in Asia and mortality rates are highest at 57.4% in Asia. When reviewing the data standardizing for age, Australia and New Zealand have the highest incidence rates, while the highest overall mortality rates are in Eastern Asia. Lung cancer is the leading cause of cancer related deaths at over 18% of all cancers globally.
In the United States, there is estimated to be over 1.7 million new cases of cancer diagnosed with over 606,880 deaths in 2019 alone. That’s approximately 3 new cases and 1 death every minute. Caring for cancer patients is expensive. The Agency for Healthcare Research and Quality (AHRQ) estimates the U.S. spent $80.2 billion for cancer care in 2015. The good news is mortality rates are down approximately 27% since its peak in 1991, and there are an estimated 16.9 million cancer survivors as of January 2019. The term “survivor” has evolved over the years and now includes individuals who live free of cancer for the rest of their life after initial treatment, as well as those that live with cancer as a chronic disease or experience a recurrence or subsequent cancer.
Why is this critically important to hospital executives?
Globally, the economic impact of cancer is significant and is increasing. The total annual economic cost of cancer in 2010 was estimated at approximately US$ 1.16 trillion. Approximately 70% of all cancer deaths come from low to middle income countries.
In the U.S. the rate of growth of health care spending is outpacing inflation according to estimates from CMS, reaching approximately $3.3 trillion in 2016, more than $10,000 for every American. At this pace Americans will be spending 20% of our entire economy on health care by 2026. Rising prices for the same services are a major source of cost growth.
Variability of costs are also associated with the type of cancer a person has and the related appropriate treatments for that cancer. According to a progress report put out by cancer.gov, while lung cancer is the most prevalent and deadly cancer overall, breast cancer is the costliest and those costs have trended up over the 8 years depicted below.
IMPACT TO HOSPITALS
Although cancer care represents a small fraction of overall health care costs, its contribution to health care cost escalation is increasing faster than those of most other areas because of several factors:
- Increasing prevalence of cancer due to the overall aging of the population and better control of some causes of competing mortality
- Introduction of costly new drugs and techniques in radiation therapy and surgery
- Adoption of more expensive diagnostic tests
In some cases, the adoption of newer, more expensive diagnostic and therapeutic interventions may not be well supported by medical evidence, thereby raising costs without improving outcomes. Coupled with, or even driving, some of these rising costs are sometimes unrealistic patient and family expectations that lead clinicians to offer or recommend some of these services, despite the lack of supporting evidence of utility or benefit.
Many hospitals have chosen to direct patients to “financial counselors” within their institutions. These associates are trained in helping patients understand and manage their costs, as well as improve hospital revenue cycle times. Many times, they have insights to grants and support organizations that can be leveraged to help defray costs to patients as well as insure that hospitals have costs covered for the services they render. This helps the hospital increase revenues and turnaround times for collections.
Please see the resource page for a booklet from Cancer.net which can be shared with patients and caregivers to provide them with more insights on how to manage costs while still accessing quality cancer care.
How to have Effective Cancer Conferences
(aka Multi-Disciplinary Tumor Boards or MTBs)
MTBs are formal, regularly-scheduled meetings in which networks of specialists devoted to the care of cancer patients meet to review individual cancer patients in a prospective manner to discuss the diagnosis and formulate management plans using an evidence-based approach. These meetings typically involve core groups of physicians including medical oncologists, radiation oncologists, surgeons, radiologists, and pathologists, as well as other ancillary members of the health care team and other allied health care professionals. The patients discussed at these meetings may be patients newly-diagnosed with cancer or may even involve patients at high risk for cancer or patients with complex management issues. Evidence has shown that MTBs can improve diagnostic accuracy, adherence to clinical practice guidelines, and some clinical outcomes.
In the U.S., the Commission on Cancer (CoC) has accredited over 1600 hospital cancer programs to determine compliance with their standards, and most hospitals globally follow similar guidelines to provide quality cancer care. One of the CoC's standards has to do with MTBs, how they are run, who attends them and their adherence to evidence-based guidelines when deciding a patient’s treatment plan.
There have been articles in the literature that has questioned the value and efficacy of tumor boards, in his article “Are Tumor Boards a Waste of Time?” Nick Mulcahy discusses data collected from 138 Veterans Affairs’ tumor boards. Study investigators found only a modest association between the presence of tumor boards and the recommended, stage-specific cancer care. These investigators identified 27 measures of quality and linked them to cancer registry and administrative data to assess receipt of stage-specific care and outcome among cancer patients diagnosed in 2001-2004; only 1 of the 27 measures was statistically significantly associated with tumor boards.
So how do we make tumor boards valuable for the doctors who attend them and most importantly their patients? According the Commission on Cancer 2016 Standards “Ensuring Patient Centered Care,” the hospital must appoint a cancer conference coordinator to monitor and evaluate the cancer conference activities. There are 7 aspects of the cancer conference that must be monitored for compliance:
- Conference frequency
- Multidisciplinary attendance
- Total number of case presentations
- Percentage of cases presented prospectively (prior to initiation of treatment)
- Discussion of cancer stage, prognostic indicators and treatment plan using evidence-based guidelines
- Options and eligibility for enrollment into clinical trials
- Adherence to cancer conference policies
Because many hospitals have condition specific case conferences, organizing and managing these meetings can be very time intensive, as well as keeping track of cases presented and attendees. The tools below are intended to assist cancer conference coordinators in organizing and managing these conferences so that they can easily report results to the overall hospital cancer committee annually.
There are also software solutions that may be leveraged to assist coordinators in managing tumor boards. For example, Oncolens has software designed to help manage data, track attendance and monitor outcomes.
Remember the primary reason for the care conference is to provide patients with coordinated, quality care in a timely fashion. Institutional support is imperative for the MTB to be successful, in return the institution can will gain secondary benefits to having cancer conferences such as increased social/marketing value, education, accreditation, quality and safety.
Timing is Important when Waiting for Diagnosis and Treatment of Cancer
The Institute of Medicine (now the National Academy of Medicine) has identified improving the timeliness of patient centeredness of care as an important unmet health care priority. They have stated that cancer may progress over time from precancerous, early stage curable tumors to advanced (less curable) cancers. Prompt diagnosis enables earlier disruption in the carcinogenesis and thus may reduce mortality.
Transparency in understanding the time to treat metric is important in improving time to treat, and when benchmarking your outcomes to other sites. The metric should be from the date of initial histological diagnosis of cancer to the earliest cancer treatment; whether it is neoadjuvant therapy, surgery, radiation therapy, etc. The team also needs to align on if this is measured in “business days” or calendar days. We suggest using calendar days since those are days important to the patient, however some benchmarks, for example those put out by the National Consortium of Breast Centers (NCBC) use business days in their calculations.
Time from a cancer diagnosis to the time treatment can be an anxiety provoking time for patients. As cancer center team members and administrators, it’s critical that you understand your role in patient wait time and address barriers to reduce it. A study done in 2014 at a major cancer center in the U.S. Midwest, found that many large academic medical centers time to treat cancer patients was over six weeks. They realized there was an opportunity to reduce that time and accomplished a 33% reduction in their time to treat; initially 39 days now 29-41 days based on if the patient was internally or externally diagnosed.
After conducting several process optimization initiatives and changing how they managed cancer patients (development of cancer type specific programs), additional staffing, and re-organization of the oncology departments, the team at this institution was able to reduce their time to treat by 33% for all cancers.
Along with reduction in treatment times, the centers enjoyed a 33% increase in NEW cancer patients and nearly 7% in compounded annual growth revenues (CAGRs).
Importance of timely intervention by cancer type
In a paper written by Bleicher, et.al. published in JAMA Oncology 2016, the authors conducted research on patients with invasive breast cancer. They used two separate data sources; the SEER data on a Medicare co-hort as well as data from the National Cancer Database. Of nearly 95,000 breast cancer patients in this study survival in early stage breast cancer was found to be affected by the length of the interval between diagnosis and surgery.
In conclusion, evidence exists that time to treat patients is an important metric to monitor and to act on when time is excessive. Creating cancer site specific teams, conducting data analysis on cancer treatment times and identifying reasons for delay can result in important, sometimes life altering outcomes to the patient and drive growth, satisfaction and revenue for the center.
Incorporation of Artificial Intelligence into the Cancer Continuum
Artificial intelligence (AI) is forecasted to be a solution to many of the administrative issues seen in health care today. Because of fragmentation, clinician shortages, legalities and costs, the real promise of AI may be best realized in the health care industry.
The global market for AI in health care is estimated at $1.9 billion, generated largely by sales in the workflow solutions market segment, followed by population health management. The health care market is expected to keep pace with the total AI market growth, reaching $11.4 billion by 2024, with a compounded annual growth rate or CAGR, of 42.6%. Markets in the United States and Europe generate most of sales, about 85%; however, strong growth from markets in Asia Pacific is expected over the forecast period.
How Does AI Impact the Cancer Continuum?
AI has been shown to improve timeliness and reduce bias in radiology studies, diagnostics and in treatment decisions for cancer patients. With health care providers now being challenged with providing value for services rendered, the ability to incorporate AI into diagnostics and treatment planning can reduce time and risk that has resulted from the fragmentation of health care delivery.
In today’s cancer care continuum, we see the best opportunity for incorporation of AI in the following areas:
Radiology- use of imaging for diagnosis is very amenable to deep-learning techniques, as images often contain a large proportion of the information needed to arrive at the correct diagnosis, the picture archiving and communication system (PACS) can be leveraged to build neural networks (machine learning where a program can change as it learns to solve a problem) and create machine learning methods based on proven algorithms.
Pathology- Histopathological assessment is the gold standard for the diagnosis of many cancer types. The procedure involves processing a biopsy or surgical specimen into tissue slides and staining the slides with pigments, and then expert pathologists interpreting the slides under a microscope on the basis of visual evaluation. However, discrepancies among pathologists have been documented, and the process is not easily scalable. Moreover, some quantitative histopathology image features that are barely noticeable by the human eye can predict the survival outcomes of cancer patients, indicating the existence of rich yet previously underutilized information in the pathology slides.
AI can be useful in the detection of several types of cancer; for example, a biopsy specimen machine learning coupled with a system for imaging live-cell biomarkers can facilitate the risk stratification of prostate and breast cancer patients. Since it is estimated that there will be a net deficit of more than 5,700 full-time equivalent pathologists by 2030, an automated system could mitigate this deficit, provide a fast and objective evaluation of the histopathology slides, and improve the quality of care for cancer patients.
For cancer patients, expediency in diagnostics will lead to quicker access to treatment; this can literally be the difference between life and death. Today’s patients are anxious for resolution to their disease state and at the same time are plagued with intense barriers to expedient care. Our studies show that it takes almost a full year for a person who has been screened and found to have some form of cancer to be formally diagnosed, treated and become a survivor. During this time, they are experiencing intense anxiety and many opportunity costs (largely from missing work), as well as financial toxicity for receiving bills for health care related expenses. All of this occurs as they see as many as five new doctors and undergo hundreds of tests to diagnose and monitor their bodies’ response to treatment.
AI and the Future of Health Care
As health care leaders, you are on the front lines of this new discovery in medicine. AI could be the possible solution for many of the challenges for cost, care coordination and risk reduction. As clinical AI systems mature, there will be an inevitable increase in their clinical use and deployment, which will lead to new social, economic, ethical and legal issues.
AI is likely to improve the quality of care by reducing human error and decreasing physician fatigue arising from routine clinical tasks. However, it may not necessarily reduce physician workload, as clinical guidelines might suggest that examinations be carried out more often for at-risk patients. If AI for routine clinical tasks is successfully deployed, it could free up time for physicians and allow them to concentrate on more sophisticated tasks and more ‘high-touch’ time with their patients.
The adoption of artificial intelligence (AI) in clinical practice can engender complex medicolegal issues, but physicians can take certain actions to shape how liability determinations will play out, according to an article published online October 4, 2019 in the Journal of the American Medical Association (JAMA).
- Learn how to better use and interpret AI algorithms, including what situations an available medical AI algorithm should be applied and how much confidence should be placed in its use.
- Encourage professional organizations to take steps to evaluate practice-specific algorithms.
- Ensure that administrative efforts to develop and deploy algorithms reflect what is truly needed in clinical care, and advocate for safeguards in the system.
- Check with malpractices insurers to determine how they cover AI in clinical practice.
So, what is required in our health care system for us to go beyond the use of AI for confirmation of decisions relative to standard of care? How can we leverage it to truly innovate and improve patient outcomes? According to Walach et.al., the following steps must be taken:
1. ROI, insurance codes, and value-based reimbursement
Financial motivation will clearly play an important role in the adoption of AI. Accordingly, the AI community will need to develop deployment models that clearly demonstrate the financial benefits to all parties concerned.
2. FDA support
The U.S. Food and Drug Administration (FDA) has recently made great strides in easing the clearance process for AI solutions to enter the market more quickly. FDA Commissioner Scott Gottlieb has made a variety of supportive statements; for example, declaring that the FDA is reconsidering its approach to regulating AI-powered software and devices. In 2018 alone, the FDA accelerated its approval process with more than 10 medical AI clearances, including Arterys for oncology.
3. Developing an IT ecosystem
An IT ecosystem that supports the simultaneous deployment of various AI solutions will become essential as more AI solutions reach the market. The challenge is to develop an infrastructure in which all AI companies can work together. Each AI solution must become agnostic enough to allow for the creation of systems combining different AI modules.
To truly become part of the standard of care in an evidence-based medical world, AI will have to supply robust evidence to support its value.
The bare minimum is, of course, in proving the accuracy of the system. This evidence exists, and the findings are encouraging, but accuracy is an insufficient metric. The coming challenge in the AI community is to provide evidence regarding the impact on actual clinical outcomes.
In conclusion, the challenge of integrating AI into the standard-of-care framework within the cancer continuum is not an easy one, but with medical facilities, AI developers, PACS and EHR vendors, radiology leaders, and governmental authorities working together, very soon patients and medical centers across the health care spectrum will be able to benefit from the extraordinary clinical benefits that AI has to offer.
Attracting and Maintaining Patients to Your Cancer Center
Cancer Center Directors are accountable for providing high quality care for their cancer patients and to work to maintain a good reputation for their center in their community. Historically, if you were the local center, you were where local patients came for care. However, today’s health care consumer is changing that paradigm, they are conducting their own research, looking for health care value; quality over cost, and aren’t limiting themselves to the geographically closest care option. So, what can you do to attract and maintain patients in your center? Below are a few ideas that are documented ways to keep your patients and their families in your cancer center.
The first thing a patient does is make sure their care is covered by their insurance carrier and ensuring your center, and their provider, is in network. The majority of U.S. cancer patients’ payor is Medicare, which includes most U.S. Hospitals and physicians in their network. But not all patients are Medicare beneficiaries, especially since cancer is being diagnosed in younger patients due to expanded screening efforts, many patients are covered by commercial insurers, so meeting their requirements for customer service and quality are extremely important to retaining their contracts, and their subscribers.
When people learn they have a serious disease, their first reaction is often, "Where's the best place in the world to go for this diagnosis?" They're often willing to travel anywhere, and they assume that's what they'll have to do. Finding a good doctor and, if necessary, a good hospital is indeed essential when you're seriously ill. But for the vast majority of illnesses, even serious ones, patients can usually find excellent care fairly close to home, especially if they live in or near a big city. However, if a patient needs an unusual or difficult procedure or operation that local doctors don't perform often enough to keep up their technical skills, patients may go to competitor facilities. Or perhaps they want to enroll in a clinical trial and your center doesn’t offer them, they will travel to get enrolled.
Other topics that patients may research about your center are:
- Quality ratings- Clinical excellence is the number one thing patients care about. So how does your hospital rank in “Hospital Compare”? Hospital Compare has information about the quality of care at over 4,000 Medicare-certified hospitals, including over 130 Veterans Administration (VA) medical centers, across the country. Patients can use Hospital Compare to find hospitals and compare the quality of their care, so you want to review your ratings and make sure they are accurate. https://www.medicare.gov/hospitalcompare/About/What-Is-HOS.html
- To understand the quality specifically around cancer services, patients can look on line to determine if your Center is Commission on Cancer Accredited. The CoC, a program of the American College of Surgeons (ACoS), recognizes cancer care programs for their commitment to providing comprehensive, high-quality, and multidisciplinary patient centered care. https://www.facs.org/quality-programs/cancer/coc
- Wait Times for services-Wait times for services can affect a patients’ willingness to come to your center for services (i.e. it takes over a week or two to get in for an appointment). Also for current patients receiving services, wait times are known to influence their satisfaction results; and their willingness to return for additional services. While some waits are unavoidable, many hospitals and health care facilities have taken steps to become more efficient and transparent. The average patient wait time in the United States was 18 min and 13 sec, according to a 2018 Vitals study. Long patient wait times affect not just the perception of care but the actual care that patients receive. In fact, up to 30% of patients have left a physician’s office before being seen because of the wait time. Twenty percent would consider changing providers over long waits.
How can Health Systems Attract Prospective Patients?
Pew research has found that 77% of consumers are using online resources to make health care decisions so we suggest:
- Build a comprehensive online review system
- Ensure online reviews are current
- Give your business a human touch
- Engage with patients’ real time
Using these tools as well as your team’s personal dedication to high quality, affordable care will assist you in maintaining and retaining your patients.
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