Experts outline path to accountable cancer care

As mounting research points to unsustainable costs in cancer treatments and a lack of clarity in oncology clinical trials, a trio of experts has proposed a new model to attain accountable cancer care—Cancer Care Groups (CCGs)—in a viewpoint published online April 29 in JAMA Internal Medicine.

Justin E. Bekelman, MD, from Abramson Cancer Center in Philadelphia, and colleagues noted that cancer care is multispecialty and occurs in multiple settings, which produces fragmentation and can lead to high costs and variability. The cancer team of surgical, medical and radiation oncology specialists plays different roles at different times in treatment. Primary care also serves an important role in management. It’s an approach at odds with accountable care.

“This unsteady balance of patient care does not fit neatly into current concepts of accountable care organizations or medical homes, which focus on primary and preventive care, or medical neighborhoods,” wrote Bekelman and colleagues.

The authors noted that uncoordinated care contributes to overuse and underuse of tests and treatment, while the fee-for-service model incentivizes physicians to order more treatments rather than practice evidence-based medicine.

They suggested CCGs, which would employ and expand the multidisciplinary tumor board approach.

“Cancer specialists would voluntarily establish CCGs with panels of surgical, radiation, and medical oncologists providing comprehensive cancer care throughout the arc of patients’ progressive cancer care needs and coordinating care with PCPs and palliative care specialists,” they wrote.

Cancer care would be linked to guideline-concordant care where it exists, which would provide the basis for bundled payments according to diagnosis and stage. Factors such as comorbidities and local cost of living also would be factored into the bundled payment. In addition, palliative care should be factored into the bundled payment for patients with metastatic disease.

The researchers acknowledged that some cancers may not fit into a relatively easy guideline-concordant mold because a large selection of “available and acceptable, but disparate, treatments” exists for some cancers.

Overall, “This bundled payment approach will reduce cost growth through incentives for cancer specialists to discontinue unnecessary or discretionary tests and therapies and to shift to lower-cost but still equivalent therapies,” the researchers wrote.

Bekelman et al offered that performance measurement would play a role and suggested bonus and withheld payments for CCGs that substantially exceed or fall short of quality and outcome measures.

They outlined several barriers to the CCG model, including:

• A lack of regulatory and legal structures to allow shared savings;
• The complex clinical course of some malignancies, which complicates bundling; and
• The minimal integration, coordination and performance feedback provided by EHRs.

“The CCG represents a new structural and payment-reform vehicle that has the potential to drive toward accountable cancer care,” the authors concluded.